97121238 THE CYCLOPEDIA OF PRACTICAL MEDICINE. VOL. I. THE CYCLOPEDIA OF PRACTICAL MEDICINE: COMPRISING TREATISES ON THE NATURE AND TREATMENT OF DISEASES, MATERIA MEDICA AND THERAPEUTICS, MEDICAL JURISPRUDENCE, ETC, ETC. edited by JOHN FORBES, M.D. F.R.S. PHYSICIAN TO THE QUEEN'S HOUSEHOLD, ETC. ALEXANDER TWEEDIE, M.D. F.R.S. PHYSICIAN TO THE LONDON FEVER HOSPITAL, AND TO THE FOUNDLING HOSPITAL, ETC. JOHN CONOLLY, M.D. LATE PROFESSOR OF MEDICINE IN THE LONDON UNIVERSITY, PHYSICIAN TO THE HOPEWELL LUNATIC ASYLUM, ETC. THOROUGHLY REVISED, WITH NUMEROUS ADDITIONS, BY ROBLEY DUNGLISON, M.D. PROFESSOR OF INSTITUTES OF MEDICINE IN JEFFERSON COLLEGE, PHILADELPHIA, LECTURER ON CLINICAL MEDICINE AT THE PHILADELPHIA HOSPITAL, ETC. " Hffic demum sunt quee non subgessit phantasies imaginatricis temeritas sed phenomena practica edocuere."—Sydenham. IN FOUR VOLUMES. VOL. I. ABDOMEN—EMMENAGOGUES. PHILADELPHIA: LEA AND BLAtfCHARD. 1845. W3 _ v-l Entered, according to Act of Congress, in the year 1845, by LEA AND BLANCHARD, in the clerk's office of the District Court of the United States for the Eastern District of Pennsylvania. J. FAGAN, STEREOTYPER. T. K. AND P. G. COLLINS, PRINTERS. C4) CONTENTS OF THE FIEST VOLUME. Todd Todd Contributora. Page —, Abdomen, Exploration of.Dr. Forbes........ 25 — Abortion............. Lee.......... 33 — Abscess............. Tweedie....... 36 —Abstinence........... M. Hall........ 42 Achor............. — Acne............. Acrodynia........... Dunglison — Acupuncture......... Elliotson . -Age................ Roget___ Air, Change of....... Clark.... - Alopecia............. Todd___ Alteratives........... Conolly .. — Amaurosis......... «- Amenorrhcea....... Anaemia v Aphthse 45 46 54 54 57 67 71 . 74 Jacob......... 78 Locock........ 89 M'Ball.....I c_ Dunglison... 5 ^ Anasarca............ Darwall....... 95 -• Angina Pectoris...... Forbes........103 Anodynes ........... Whiting......117 Anthelmintics........ A. T. Thomson .119 Anthracion .......... Dunglison.. .. 122 Antiphlogistic Regimen. Barlow.......122 Antispasmodics....... A. T. Thomson . 124 ■"» Aorta, Aneurism of___ Hope.........126 „ Aphonia............. Robertson......139 Robertson Dunglison ^ Apoplexy, (Cerebral) .. f Apoplexy, (Pulmonary) >- Arteritis............. „_ Artisans, Diseases of. .. _ Ascites.............. *. Asphyxia............ Roget.........188 . Asphyxia of the newborn Dunglison.....205 ^, Asthma............. Astringents.......... •. Atrophy ............ .-. Auscultation......... Barbiers............. Bathing............. Beriberi............. Blood, determination of - Blood, Morbid States c of..............I «- Bloodletting.......... s- Brain, Inflammation C Quain...... of..............£ Adair Crawford *■ Bronchial Glands, Dis- ease of the......, .. Dunglison.....331 Bronchitis.........\ Williams.... £ 33] (_ Dunglison... 5 " Summer..... Dunglison.....342 .» Bronchocele.......... And. Crawford. 343 Bulla;............... Todd..........352 Cachexia............ Dunglison.....353 ^ Calculi.............. Thos. Thomson.354 «• Calculous Diseases..... Thos. Thomson.365 * Catalepsy............ Joy..........378 * Catarrh............. Williams......382 Cathartics........... A. T. Thomson . 385 * Chest, Exploration of.. Forbes........391 " * 1140 Clutterbuck ... 142 Townsend..... 155 Hope.........163 Darwall.......170 Darwall.......182 Forbes........206 A. T. Thomson.229 Townsend.....234 Forbes........237 Scott..........264 Forbes........266 Scott..........287 Barlow........290 Marshall Hall Dunglison Marshall Hall. .296 11} 291 301 Chicken-Pox.........Dr Chlorosis............ Cholera............. Cholera Infantum...... Chorea.............. Cirrhosis of the Lung . Climate.............. Cold.-,..:........... Colic.............$ Colica Pictonum...... Colon, torpor of the ... Coma............... Combustion, Spontane- ous Human........ Congestion of Blood... Constipation...... ontagion - -tV"........ Convalescence........ Convulsions.......... Convulsions, Infantile. . Convulsions, Puerperal. Coryza.............. ^Counter-Irritation..... !«Croup.............. > Croup of the adult .... uCyanosis........... Cystitis............. Dead, persons found.... Delirium............ Delirium Tremens.. . < Dengue ............. Dentition, Disorders of . Derivation........... Diabetes............. Diagnosis............ Diaphoretics.......... r-Diarrhoea..........3 Diarrhoea, adipous..... Dietetics............ isease.............. Disinfectant-s-rr....... Disinfection.......... Diuretics.. 77777...... ropsy.............. Dysentery........... LDysmenorrhcea ....... |» Dysphagia........... j. Dyspnoea............ >»Dysuria.............. ^-Ecthyma............ [•Eczema.............. l«Education, Physical... . Electricity........... Elephantiasis Arabum.. Elephantiasis Grsecorum Emetics............. Emmenagogues....... Contributors. Page Gregory.......395 M.Hall.......396 Brown........399 Dunglison.....426 And. Crawford.427 Dunglison.....440 Clark........440 Whiting.......453 Whiting .... 7 45g Tweedie.....5 Whiting......463 Dunglison.....466 Adair Crawford.466 Apjohn........470 Barlow........476 Hastings---7 . Streeten.....5 " Brown........500 Tweedie.......505 Adair Crawford.508 Locock........519 Locock........522 Williams......524 Williams......526 Cheyne.......534 Dunglison.....542 Crampton.....542 Cumin.......545 Beatty........548 Prichard......582 cnarter.:.....I 587 Dunglison... 3 Dunglison.....594 Joy..........595 Stokes........601 Bardsley......606 Hall..........625 A. T. Thomson.626 Crampton... ■> Forbes......5 Dunglison .... 642 Paris.........642 Conolly.......674 Dunglison.....689 Brown........690 A. T. Thomson.695 Darwall......701 Brown........720 Locock........728 Stokes........730 Williams......732 Cumin.......734 Todd.........737 Joy..........743 Barlow.......750 Apjohn........765 Scott..........770 Joy..........773 A. T. T/iomson. 776 A. T Thomson. 784 (5) 150 PEEFACE FEOM THE ENGLISH EDITION. The Editors have at length the gratification of laying the Cyclopedia op Prac- tical Medicine before the public in a completed state. It is impossible for them to look at the list of the Contributors by whose assist- ance this work has been accomplished without a deep-felt satisfaction; distinguished as that list is by so many names of celebrity in modern medicine, and including so many of the professors and teachers in London, Edinburg, Dublin, and Glasgow, whose reputation conveys a high and just authority to their doctrines. To have directed some part of the scientific exertions of such writers to the pages of the Cyclopsedia, and, also, to have elicited from not a few of the most accomplished among the provincial physicians of the empire, numerous and valuable contributions which but for the comprehensive plan of this work might never have been commu- nicated to the profession, is a result to which the Editors must ever feel proud and gratified to have conduced. With such efficient aid in all the parts of their undertaking, they have spared no personal pains, in the hope by uniformity of plan, simplicity of arrangement, and the harmony and consistency of its several portions, to make the Cyclopaedia fully and fairly to represent the state of Practical Medicine at the time of its appearance. From innumerable foreign and domestic sources the scattered know- ledge which has so fast accumulated since the commencement of the present century has thus been gathered together, and placed at the command of every reader of the English language. Those acquainted with the actual limitation of such knowledge before the appearance of this work, and who have opportunities of knowing how slowly even valuable novelties are diffused in a form giving any assurance of their worth, will best be able to appreciate the importance of the extensive means of reference which the Cyclopaedia has at once introduced into the library of many English practitioners at home and abroad. The ambition of the Editors was not limited to the formation of a mere manual, fitted for those who only demand the smallest supply of exact intelligence with which practice can be carried on, or professional station maintained without a palpable exposure of ignorance. Their object was no less than to prepare a com- pendium of the best parts of ancient and modern medicine, theoretical and practical; not passing over with disregard the vast literature of the ancient writers, but rather rescuing it from the voluminous oblivion in which much of it was lost; and also collecting with care the more accurate, condensed, and applicable knowledge of modern authors and of modern times into a liberal and consistent system, from works little known to the generality of English readers, and familiarly known to very few. Thus, whilst the great claims of the older cultivators of medicine have never been forgotten, the labours of the moderns, and more particularly of the French, German, and Italian pathologists, by which, conjointly with those of British prac- titioners, the whole face of practical medicine may be said to have been changed, have attracted the most diligent and thoughtful attention. The learned reader (vii) Vlll PREFACE FROM THE ENGLISH EDITION. does not require to be assured that the task of reference for specific information to many older works, once of high and deserved authority, and still esteemed, is often both tedious and little profitable, whilst their ample volumes yet contain much valuable matter, not unworthy of preservation, and which it is no fruitless employ- ment to endeavour to place along with the better arranged facts of later writers, in one view, before the practitioner and the student. Throughout the prosecution of this large design, it has never been forgotten that the Cyclopaedia would be referred to by various readers for various objects; by the young practitioner as the guide and counsellor of practice, especially when beset with practical difficulties; by the older practitioner for complete and concise information, and for medical learning not scanty and illiberal, but without scholastic pedantry; and by the student for applicable knowledge, suited to the actual time, collateral with and auxiliary to his prescribed studies, and satisfactorily directing the efforts of his inquiring mind. At the commencement of such an undertaking, it was difficult not to call in question the probability of its meeting with adequate encouragement. No such work existed in this country; and although works on a plan somewhat similar had been very favourably.accepted on the Continent, still it might have been urged that the English were eminently, almost exclusively, a practical people, — that their medicine, in the opinion of foreign critics, who appeared to be dispassionate and impartial, was essentially empirical,—and that until a very recent period undeniable prejudices existed in the minds of many English practitioners of known practical skill, against all attempts to append theory to the deductions of mere experience. Of the English works known to have been most profitable to their publishers, many were mere compilations, or of a description adapted to the contracted prejudices just alluded to; whilst works which have been thought deserving of translation into more than one foreign language, and had reflected honour on British pathology, had in our own country met with comparative neglect. The progress of medicine during the last forty years had led to successive editions of the few systematic works already existing, to which the recent acquisi- tions of medical science were somewhat inconveniently, because incongruously, attached. The cultivation of general anatomy, the changes effected in physiology, and the immense advancement of the knowledge of morbid structure, required that the whole of Practical Medicine should be presented in that reconsidered and augmented state which had been the result of this progression. Several parts of medical study, bearing closely upon practice, had moreover undergone so much recent investigation as almost to constitute them new parts of medical science ;— such as the effects of Climate on health and disease ; the properties of Mineral Waters; the mode of action of Poisons, and indeed the whole subject of Medical Jurisprudence; as well as the new methods of exploring diseases of the chest and abdomen; the laws of epidemics, and the means of promoting disinfection; with many other questions of considerable interest. The greater intercourse which had taken place during a period of nearly twenty years of peace, between this country and the Continent, had opened vast stores of pathological facts in connection with almost every known disease, which yet remained imperfectly known to many to whom a general work would be accessible, and which no editor had yet sought to arrange and collate with the contemporaneous discoveries of our own authors, or to combine with the practical improvements acknowledged in our own country. Between respect for the old writers, and the continual contradictions of them occurring in those of later date ; between the fame of the Continental authorities, PREFACE FROM THE ENGLISH EDITION. ix and a lingering attachment to opinions of which all the foundations had been shaken; the student of medicine and the young practitioner found themselves embarrassed in the attempt to arrive at stable conclusions, or even to comprehend (he actual state at which medicine had arrived, and which no general work at that t.me represented. All these circumstances encouraged the presumption that if a work embodying all these improved parts of medical knowledge,—simply and conveniently arranged, and not unenriched by the treasures of an older period—full and accurate, but from which all the superfluous matter that had been admitted into some foreign works of a like form was carefully excluded, — were offered in the English language, its reception would be such as to satisfy all who were concerned in it, whilst its pre- paration would reflect no discredit on those who undertook it. It was in no small degree gratifying to the Editors to find that the publication of the early numbers of the Cyclopaedia was attended with circumstances which conveyed an assurance of the general correctness of these views. The circulation of the work soon extended to every portion of the British empire, to the Colonies. and to America; and the publishers have from time to time informed them that its sale was steadily proceeding. The Editors have undoubtedly received these inti- mations with pleasure; not only because they were connected with benefit derived by those who had adventured in a liberal undertaking, but because they thought they perceived in such circumstances a proof of an increasing zeal for exact and comprehensive knowledge on the part of British practitioners of every rank, in every part of the world. However natural and proper it may be for the Editors to take a retrospective survey of the work when it is brought to a conclusion, and to examine with what fidelity they have fulfilled their engagements, and how far and how equally the various departments of practical medicine have in their turn occupied their atten- tion, it is hardly possible to express 7the results of this retrospection in words which will not expose them to the charge of being disposed to look back upon their exer- tions with too much complacency. Yet they may perhaps be allowed to say, that if the reader will take the trouble to inspect the mere titles of the articles con- tained in these columns, comprehending nearly three hundred original essays of known and distinguished authors, and will bear in mind either the leading physio- logical divisions of diseases, or consider them with reference to the head, the chest, the abdomen, the surface, or the general condition of the body; as well as the subjects of obstetrical medicine, materia medica, or medical jurisprudence ; he will sufficiently appreciate the care bestowed to make the Cyclopaedia satisfactory to all who refer to its pages, and at the same time strictly a book of practical reference. No subject, it is believed, immediately practical in its nature or appli- cation, has been left out, although unnecessary disquisition has been as much as possible avoided. It has consistently entered into their plan to admit of a far wider range of subjects than appears heretofore to have been considered necessary in works pro- fessedly written on the practice of medicine, but a range comprising many new subjects of extreme importance to those engaged in practice or preparing for it. Such are the subjects of Abstinence, Acupuncture, Age, Change of Air, Antiphlo- gistic Regimen, Asphyxia, Auscultation, Bathing, Bloodletting, Morbid States of the Blood, Climate, Cold, Contagion, Convalescence, Counter-irritation, Derivation, Congestion and Determination of Blood, Dietetics, Disinfection, Physical Educa- Vol. I.—V x PREFACE FROM THE ENGLISH EDITION. ticn, Electricity, Endemic Diseases, Epidemics, Expectoration, Exploration of the Chest and Abdomen, Galvanism, Hereditary Transmission of Disease, Induration. Irritation, Infection, Latent Diseases, Malaria and Miasma, Perforation, Prognosis, Pseudo-morbid Appearances, Pulse, Softening, Medical Statistics, Stethoscope, Sudden Death, Symptomatology, Temperament, Toxicology, Transformations, Trans- fusion, Tubercle, Ventilation, Mineral Waters ; and those of various general arti- cles on the pathology of organs. The several articles relating to Diseases of the Brain and Spinal Chord, and of their membranous coverings, including the important subject of the impairment of the mental manifestations, will probably be deemed by every candid reader to contain accurate views of morbid structure and faithful descriptions of the most important lesions of the nervous functions. How great the talent and how high the authorities on these subjects, will be at once seen by referring to the names of the authors of the articles Apoplexy, Inflammation of the Brain, Catalepsy, Chorea, Coma, Convulsions, Delirium, Epilepsy, Headach, Hydrocephalus, Hydrophobia, Hypochondriasis, Insanity, Latent Diseases, Paralysis, Plethora, Prognosis, Som- nambulism, Diseases of the Spinal Marrow, Temperament, Tetanus, Wakefulness, &c. As regards the greater number of the authors of these articles, they are well known to have been previously in much esteem with the public for treatises more or less connected with the subjects on which they undertook to write for the present work. The direction for many previous years of the attention of one of the Editors to Diseases of the Chest could not but make both him and his colleagues particularly desirous that on the subjects of the numerous and serious diseases of the lungs and of the heart, the Cyclopaedia should contain the fullest and the most recent informa- tion ; and that the novel and still too much neglected methods of physical investi- gation of Auenbrugger, Laennec, Andral, Piorry, and others, should be clearly and perfectly set forth. In the articles relating to these various maladies, contributed by Dr. Carswell, Dr. Cheyne, Sir James Clark, Dr. Darwall, Dr. Hope, Dr. Johnson, Dr. Law, Dr. Townsend, Dr. Williams, &c. it is hoped that no omissions will be found. These names are for the most part so familiar to the profession, in connection with the several subjects on which they have written in the Cyclopaedia, that the titles of the different articles would alone have suggested them, in order to give the stamp of valuable authority to each. As regards Diseases of the Abdomen, it may without any impropriety be men- tioned that, in the articles Cholera, Colic, Diarrhoea, Dysentery, Enteritis, Epidemic Gastric Fever, Gastritis, Gastrodynia, Gastro-enteritis, Heematemesis, Hemorrhoids, Indigestion, Jaundice, Inflammation of the Liver, Peritonitis, Pyrosis, Tabes Mesenterica, Tympanites, Worms, Organic Diseases of the Stomach, Liver, Pancreas, Kidneys, &c. &c, is included a more elaborate and practical exposition of the pathology and symptomatology of the affections of the abdominal viscera generally, and of the gastro-intestinal mucous membrane in particular, than is contained in any single work previously published. The importance of correct views of this large class of common and much diversified disorders, as a basis of useful practice, is such as it would be quite needless to dilate upon. They involve consequences most seriously affecting the health of the body and the mind; and the mismanagement even of the lighter forms is largely productive of human dis- comfort and unhappiness. They are also, in some form or other, incidental to every constitution, and are literally of daily and hourly occurrence. From fever, the severest of the acute diseases from which medical care effects frequent recovery, PREFACE FROM THE ENGLISH EDITION. xi to the habitual distresses produced by the imperfect digestion of food, they demand the continual attention of the practitioner. The relations of gastro-intestinal irritation with numerous disorders of the chest, head, skin, and extremities, and with fever, as causes or effects, are among the most interesting questions which have been agitated by the most eminent of modern physicians in this and in other countries, and the practical application of the researches of pathologists concerning the morbid states of the digestive mucous membrane remains an object anxiously sought by those acquainted with the exigences of various practice, and who are not content to practise without reflection. So indiscriminate, also, generally speaking, is the treatment of the various modi- fications of indigestion,—the chronic irritations of the intestines are often so long overlooked,—so empirically are undefined disorders of the liver prescribed for,— and the conduct of the dietetical part of practice, even in fevers, and still more in chronic disorders, is so capricious,—that it may be permitted to the Editors to hope that some improvement may ensue from the circulation of the sounder and better founded notions of pathology and practice explained and advocated in the various essays on abdominal diseases which contribute to give value to these volumes. The department of Cutaneous Diseases has, it will be seen, engaged the pens of Dr. Corrigan, Dr. Cumin, Dr. G. Gregory, Dr. Houghton, Dr. Joy, Dr. Kerr, Dr. A. T. Thomson, and Dr. T. J. Todd, by whom, as was to be expected, this important branch of study, which enjoys but a small share of popularity in this country, has received full pathological and practical illustration. As regards some affections implicating the whole system, and particularly the fluids, it is but just to allude to the admirable treatises on Gout and Plethora, as being worthy of the high reputation before attained by the author of them as a philosophical physician and an experienced practitioner. Nor can the Editors pass silently over the elaborate article on Tubercular Phthisis, of which it is but one among many excellences that it invites the attention from that contemplation of local lesions which leads to practical results of little value, to a more enlarged con- sideration of the subject, pregnant with the most momentous practical consequences. The names of Dr. Marshall Hall, Dr. Lee, Dr. Locock, and Dr. Montgomery, affixed to the several articles connected with the Diseases of Women and Children, will be a sufficient assurance to every reader that this responsible part of medicine has not been confided to inefficient hands. Nothing could be more compatible with the plan of the Cyclopaedia than the brief, clear, and instructive essays furnished by these able and experienced practitioners. In the interesting field of Medical Jurisprudence the work has been benefited by the original and masterly dissertations of Dr. Arrowsmith, Dr. Beatty, Dr. Christison, Dr. Montgomery, and Dr. Prichard. The well-earned fame of Dr. A. T. Thomson gives to his numerous contributions on subjects comprehended in the department of the Materia Medica, an interest of which every student must be fully sensible ; and it is but just to mention that for the limitation of these articles within narrower bounds than those which the author deemed essential to their full value, the Editors are solely accountable. With respect to the practical application of some other medical agents, as Galva- nism and Electricity, the reader is enabled to avail himself of the valuable informa- tion communicated by Dr. Apjohn, and marked by his characteristic accuracy. To the same able writer the Editors, have been indebted for the comprehensive treatise on Toxicology. In the parts of the work closely allied to chemical science, as in the articles Calculi and Mineral Waters, the Editors have been honoured by the xii PREFACE FROM THE ENGLISH EDITION. contributions of Dr. Thomas Thomson, of Glasgow, who has been long known to the whole scientific world as one of the greatest authorities in modern chemistry. The value of the aid afforded in the general articles relating to various parts of Morbid Anatomy, will be understood by all who know the great and deserved reputation of Dr. Cars well, both in England and on the Continent; a reputation which cannot but derive increase by his great work on that subject, and its incom- parable pictorial illustrations, now in the course of publication. Many able contributions, not specially alluded to in these observations, demand the general and warm acknowledgements of the Editors, as of a character not inferior to any which have been mentioned; and their especial obligations to Dr. Alison and Dr. Bostock will be evident to all who peruse with attention the Histo- rical sketches prefixed to the practical portion of the Cyclopaedia. As tending in a considerable degree to place the contents of the work more completely before the reader for immediate consultation, and therefore important, although laying no claim to merit in itself, the Editors have added a very minute and extensive General Index. Hoping to be excused for making these reflections on a work now laid before the profession in a finished state, the Editors will only add, that they have avoided multiplied and artificial divisions, and have aimed at that plainness of arrangement which most facilitates a ready and immediate reference. They have also shunned the fault of encumbering medical literature with new and uncouth terms, always preferring those in common use, and of which the signification was the least doubtful. It has been their constant desire to guard the most inexperienced reader from distraction in the pursuit of practical knowledge, and to assist the more advanced reader in the grouping and generalization of the ideas with which his personal experience may have imbued him. One of the most delicate parts of the duty of the Editors in conducting these pages from their commencement to their termination, has been the occasional adaptation of the articles composing it to the character or to the proposed size of the whole work. Considerations which could not properly be put aside sometimes caused modifications to be absolutely necessary, in contributions which might have been published unchanged as separate essays. To say that this duty was in every case performed without difficulty, or with the entire and ready acquiescence of the writers, would be to assert what none who are versed in literary composition, or who know the natural feelings of authors, would give credit to. That it was always performed with a sincere regard to such feelings, and that no change of arrange- ment, and even no verbal alteration, was made without just deliberation, they may very truly affirm. They have the satisfaction of believing that such is the impres- sion left on the minds of those contributors who have honoured them with their assistance. With many, before unknown to them, except by reputation, the Editors have the happiness to feel assured that permanent freindship has arisen out of what was at first but casual co-operation. In conclusion, the Editors entertain a hope that they have prepared a work required by the present wants of medical readers, acceptable to the profession in general, and so capable by its arrangements of admitting the progressive improve- ments of time, as long to continue what the general testimony of their medical brethren, as far as it has hitherto been expressed, has already pronounced it to be, a standard British work on the Practice of Medicine. If such should prove to be the event, they will feel themselves abundantly repaid for the labours which it has imposed upon them. PEEFACE OF THE AMEEICAN EDITOE. It is now upwards of twenty years since the undersigned agreed to engage with Dr. Copland and the late Dr. Gordon Smith, in the preparation of an Encyclopsediac Dictionary of Practical Medicine, which should hold the same relation to the department of Medicine, that Mr. S. Cooper's Sur- gical Dictionary does to that of Surgery. The project was conceived and advertised in the year 1824, in the " London Medical Repository," of which Dr. Copland and the undersigned were editors. A prospectus of the under- taking was drawn up, and arrangements were made for its publication with the Messrs. Underwood, of London. Towards the latter end of that year, the undersigned left England for the University of Virginia; and the panic, which prevailed in 1825 in the commercial world, according to Mr. Petti- grew, (Medical Portrait Gallery, Art. Dr. Copland,) caused the publishers to relinquish the undertaking. It probably, however, gave the impulse to the appearance of the " Cyclopedia of Practical Medicine," of Drs. Forbes, Tweedie, and Conolly. Of the signal value of this great work, there is but one sentiment. The general voice of the profession everywhere has, indeed, sufficiently shown, that the hope expressed by the British editors, in their Preface, has been amply realized. It is admitted, that they have prepared a work required by the present wants of medical readers, acceptable to the profession in general, and in all respects " a standard work on the Practice op Medicine." It was for this reason, and owing to the high opinion expressed of its merits by those on this side of the Atlantic, who had the good fortune to consult its pages, and to the anxiety of the best informed that it should be rendered more available to the pro- fession in this country, that the publishers determined, at a great outlay of money and of labour, to reprint it. At their request, the undersigned consented to superintend the repub- lication, to revise the various articles, and to make such additions and modifications as he might deem desirable. To this determination he was impelled, in part, by his knowledge of the accomplished editors, and his consequent anxiety, that the different articles should be preserved, as far as practicable, in their pristine integrity. Generally speaking, they were so full and comprehensive, that but little modification seemed to be necessary. In all cases, however, the undersigned has endeavoured to add the facts and B (*»•) xiv PREFACE.OF THE AMERICAN EDITOR. opinions, which form part of the medicine of the day, and to omit nothing calculated, in his view, to throw additional light on the subjects canvassed. These additions he has striven to make in such a manner as not to interfere with the general tenor of the articles; and to cause them to read as if they had proceeded from the pen of the original writers. The interstitial additions are enclosed in brackets [ ]. Besides these, he has inserted different topics, which had been wholly omitted in the English edition, some of which are essentially American in their character. To these additions his signature is appended. For one article, on the History of American Medicine before the Revolution, he is indebted to Dr. J. B. Beck, of New York. In making these additions, the undersigned has endeavoured to be as brief as perspicuity would permit; and, where his opinions have been fully expressed elsewhere,—to avoid repetition, he has referred to them for further details. On every occasion he has been anxious to cite the views and observations of cotemporary, and particularly of American, writers, where such views and observations appeared to him to merit especial notice. Appearing, as the work originally did, in parts, articles were necessarily omitted in their proper places, and many were thrown into a supplement. This defective arrangement has been rectified as far as was practicable, so that the American edition will, in this respect, be found to possess advan- tages, as a book of reference, over its English prototype. The History of Medicine, which, in the English edition, was prefixed to the alphabetic portion, takes its proper place in the third volume of the American edition. One subject only has been omitted—Medical Bibliography—which formed an appendix to the last volume of the English edition, and was subsequently published in a distinct form. This the publishers determined to discard, in consequence of the additional cost to the purchaser, which its insertion would occasion; and of their conviction, that notwithstanding its intrinsic value to a few, and the high character of its author—Dr. Forbes—it would be considered wanting in interest and importance to the many on this side of the Atlantic, who will seek the work as a guide to Practical Medicine. ROBLEY DUNGLISON. LIST OF THE CONTEIBUTOES TO THE CYCLOPEDIA OF PRACTICAL MEDICINE, AND OF THE ARTICLES WRITTEN BY EACH AUTHOR. Alison, W. P., M.D. F.R.S.E. Professor of Medicine in the University of Edinburgh, &c. Medicine, history of, in the present century. Apjohn, James, M. D. M.R.I.A. Professor of Chemistry to the Royal College of Surgeons in Ireland. Combustion, spontaneous human. Electricity. Galvanism. Toxicology. Arrowsmith, R., M.D. Physician to the Co- ventry Dispensary. Infanticide. Ash, Edward, M.D. Physician to the Norwich Dispensary. Hiccup. Prognosis. Syncope. Bardsley, James L., M. D. Physician to the Manchester Royal Infirmary, Dispensary, &c. Diabetes. Hydrophobia. Barlow, Edward, M.D. Physician to the Bath United Hospital and Infirmary. Antiphlogistic regimen. Congestion of blood. Determination of blood. Education, physical. Gastrodynia. Gout. Plethora. Rheumatism. Beatty, Thomas Edward, M.D. Professor of Medical Jurisprudence to the Royal College of Surgeons in Ireland, and Consulting Accoucheur to the Baggot-Street Hospital, Dublin. Impotence. Dead, persons found. Rape. Sex, doubtful. Survivorship. Wounds, death from. Beck, J. B., M.D. Professor of Materia Medica, in the College of Physicians and Surgeons, New York. Medicine, American, before the Revolution, History of. Bigsby, John J., M.D. F.L.S. Senior Physi- cian to the Newark Dispensary. Spleen, diseases of. Bostock, J., M.D. V.P.R.S. F.L.S. F.G.S. &c. &c. Medicine, history of. Pulse. Urine, morbid states of the. Brown, Joseph, M.D. Physician to the Sun- derland and Bishopwearmouth Infirmary. Cholera. Contagion. Disinfection. Dysentery. Fever, intermittent. remittent. hectic. Hereditary transmission of disease. Infection. Malaria and miasma. Plague. Ventilation. Burder, Thomas H., M.D. Member of the Royal College of Physicians, London. Erethismus mercurialis. Headach. Jaundice. Burne, John, M.D. Physician to the Carey- Street Dispensary. Otalgia and Otitis. Hemorrhoids. Carswell, Robert, M.D. Late Professor of Morbid Anatomy in the University of Lon- don. Induration. Melanosis. Mortification. Perforation of the hollow viscera. Scirrhus. Softening of organs. Tubercle. (xv) xvi LIST OF COI Carter, H. W., M.D. F.R.S.E. Physician to the Kent and Canterbury Hospital. Delirium tremens. Ischuria renalis. Kidneys, diseases of. Nephralgia and Nephritis. Pancreas, diseases of the. Cheyne, John, M.D. F.R.S.E. M.R.I.A. Phy- » sician-General to the Forces in Ireland, &c. Croup. Epilepsy. Fever, epidemic gastric. Laryngitis. Wakefulness. Christison, Robert, M.D. Sec. R.S.E. Pro- fessor of Materia Medica and Therapeutics in the University of Edinburgh, &c. Latent diseases. Clark, Sir James, M.D. F.R.S. Physician to the Queen and Prince Albert, &c. Air, change of. Climate. Tubercular phthisis. Clutterbuck, Henry, M.D. Physician to the General Dispensary. Apoplexy, cerebral. Conolly, John, M.D. late Professor of Medi- cine in the London University, and Physi- cian to the Hanwell Lunatic Asylum. Alteratives. Disease. Hysteria. Medicine, practical, principles of. Corrigan, Dominick J., M.D. Physician to Jervis-Street Hospital, Dublin. Pemphigus. Plica Polonica. Rupia. Crampton, John, M.D. M.R.I.A. King's Pro- fessor of Materia Medica, Physician to Stee- ven's Hospital, &c. Dublin. Cyanosis. Diarrhoea, (with Dr. Forbes.) Crawford, Adair, M.D. Assistant Physician to the London Fever Hospital. Brain, inflammation of the substance of (Cere- britis). Coma. Convulsions. Inflammation, (with Dr. Tweedie.) Crawford, Andrew, M.D. Physician to the Hampshire County Hospital, Winchester. Bronchocele. Chorea. Cumin, William, M.D. Member of the Faculty of Physicians, Glasgow. Calculus, pathology and treatment. Cystitis. Dysuria. Incontinence of urine. Pityriasis. Psoriasis. Rickets. Scrofula. Sycosis. ■Darwall, John, M.D. Physician to the Bir- mingham General Hospital. Anasarca. Artisans, diseases of. Ascites. Dropsy. Hydropericardium. Hydrothorax. CEdema. TRIBUTORS. Duesbury, Frederick, M.D. Physician to the Dispensary, and to the Invalid Asylum, Stoke Newington. Transformations. Dunglison, Robley, Professor of the Institutes of Medicine in Jefferson Medical College, Philadelphia, and attending Physician to the Philadelphia Hospital. Besides the interstitial additions, the following distinct articles: Acrodynia. Anaemia, (with Dr.. Marshall Hall.) Anthracion. Aphthae, (with Dr. A. Robertson.) Asphyxia of the newborn. Blood, morbid states of, (with Dr. M Hall.) Bronchial Glands, diseases of the. Bronchitis, summer. Cachexia. Cholera infantum. Cirrhosis of the lung. Colon, torpor of the. Croup of the adult. Delirium tremens. Dengue. Diarrhoea, adipous. Disinfectant. Enteritis, (with Dr. Stokes.) Eutrophic. Fever, malignant remittent. Galvanism, (with Dr. Apjohn.) Glanders. Heart, polypus of the. Intussusception. Jaundice of the infant. Laryngitis, chronic. Milk-sickness. Mind, soundness and unsoundness of, (with Dr. Prichard.) Molluscum. Nauseants. Ophthalmia, (with Dr. Jacob.) Palpitation, (with Dr. Hope.) Parturients. Ptyalism. Rheumatism, (with Dr. Barlow.) Sedatives, (with Dr. A. T. Thomson.) Spermatorrhoea. Spleen, diseases of the, (with Dr. Bigsby.) Statistics, medical, (with Dr. Bisset Hawkins.) Stomatitis. Strophulus. Throat, diseases of the, (with Dr. Tweedie.) Toothach. Toxicology, (with Dr. Apjohn.) Elliotson, John, M. D. F.R.S. Physician to St. Thomas's Hospital, and late Professor of Medicine in the London University. Acupuncture. Neuralgia. Forbes, John, M.D. F.R.S. Physician in ordi- nary to her Majesty's Household, &c. Abdomen. Angina pectoris. Asthma. Auscultation. Bathing. Chest, exploration of. Diarrhoea (with Dr. Crampton.) Feigned diseases, (with Drs. Scott and Marshall.) Gillkrest, J., M.D. Deputy Inspector-Gene- ral of Hospitals, London. Fever, yellow. Goldie, George, M.D. Shrewsbury, late Phy- sician to the York County Hospital. Hrematemesis. Melajna. Purpura. Urine, bloody. (Hematuria.; Grant, James, M.D. Jedburgh. Nyctalopia. LIST OF CONTRIBUTORS. XV11 Gregory, George, M.D. Physician to the Small-pox Hospital. Chicken-pox. Small-pox. Vaccination. Varicella. Hall, Marshall, M.D. F.R.S. L. & E. &c. Abstinence. Anaemia. Blood, morbid states of. Bloodletting. Chlorosis. Diagnosis. Puerperal diseases. Symptomatology. Hancock, Thomas, M.D. Liverpool. Endemic diseases. Epidemics. Influenza. Hastings, Charles, M.D. Physician to the Worcester Infirmary, &c. Constipation, (with Dr. Streeten.) Hawkins, Bisset, M.D. F.R.S. Professor of Materia Medica and Therapeutics in King's College, London. Statistics, medical. Hope, J., M.D. F.R.S. Assistant Physician to St. George's Hospital,' London. Aorta, aneurism of. Arteritis. Dilatation of the heart. Heart, diseases of the. Heart, fatty and greasy degenerations of. Heart, diseases of the valves of the. Heart, hypertrophy of the. Palpitation. Pericarditis and carditis. Houghton, James, M.D. Physician to the South-Eastern Dispensary, Dublin. Lepra. Lichen. Noli me tangere, or Lupus. Pneumothorax. Scabies. Urticaria. Stomach, organic diseases of. Jacob, Arthur, M.D. M.R.I.A. Professor of Anatomy to the Royal College of Surgeons in Ireland. Amaurosis. Ophthalmia. Johnson, Charles, M.D. Professor of Mid- wifery to the Royal College of Surgeons in Ireland. Hooping-cough. Joy, William Bruce, M.D. Fellow of the King and Queen's College of Physicians in Ireland, and Physician to the Dublin Gene- ral Dispensary. Catalepsy. Dentition, disorders of. Eczema. Elephantiasis Graecorum. Erythema. Fever, infantile remittent. Glottis, spasm of the. Hydrocephalus. Tabes mesenterica. Worms. Kay, J. P., M.D. Physician to the Ardwick and Ancoats Dispensary, Manchester. Transfusion. Vot. I. —3 b* Kerr, William, M.D. Physician to the North- ampton General Infirmary. Epistaxis. Fungus {nematodes. Glossitis. Hydatids. Parotitis. Pellagra. Pyrosis. Scorbutus. Tympanites. Yaws. Law, Robert, M.D. Fellow of the King and Queen's College in Ireland, Physician Ex- traordinary to Sir Patrick Dun's Hospital. Haemoptysis. Pleurisy, pleuritis. Lee, Robert, M.D. F.R.S. Physician to the British Lying-in Hospital, London. Abortion. Fever, puerperal. Ovaria, diseases of the. Phlegmasia dolens. Uterus and its appendages, pathology of the. Veins, diseases of the. Locock, Charles,M.D. Physician-accoucheur to the Queen, Physician to the Westminster General Lying-in Hospital, &c. Amenorrhoea. Convulsions, infantile. Convulsions, puerperal. Dysmenorrheas. Lactation. Leucorrhoea. Menorrhagia. Menstruation, pathology of. MacAdam, David H., M.D. Physician to the South-Eastern General Dispensary, Dublin. Peritonitis, (with Dr. Stokes.) Montgomery, William F., M.D. Fellow and Professor of Midwifery, to the King and Queen's College of Physicians in Ireland. Identity, personal. Pregnancy and delivery, signs of. Rubeola. Succession of inheritance.—Legitimacy. Paris, J. A., M.D. F.R.S. President of the Royal College of Physicians, London. Dietetics. Prichard, J. C, M.D. F.R.S. Physician to the Infirmary and to St. Peter's Hospital, Bristol. Delirium. Hypochondriasis. Insanity. Somnambulism and animal magnetism. Mind, soundness and unsoundness of. Temperament. Quain, Jones, M.D. Professor of Anatomy ! and Physiology in the London University. Brain, inflammation of the membranes of, (Me- I ningitis.) I I Robertson, Archibald, M.D. Physician to the Northampton General Infirmary. Aphonia. Aphthre. Roget, P. M., M.D. Sec. R.S. Consulting Physician to the Queen Charlotte's Lying- in Hospital, and to the Northern Dispensary, &c. Age. Asphyxia. TRIBUTORS. xviii LIST OF COS Scott, John, M.D. Edinburgh. Barbiers. Beriberi. Elephantiasis Arabum. Feigned diseases, (with Drs. Forbes and Mar- shall.) Stokes, William, M.D. Physician to the Meath Hospital, Dublin. Derivation. Dysphagia. Enteritis. Gastritis. Gastro-enteritis. Liver, inflammation of. Peritonitis, (with Dr. MacAdam.) Streeten, Robert J. N., M.D. Physician to the Worcester Dispensary. Constipation, (with Dr. Hastings.) Symonds, J. A., M.D. Physician to the Gene- ral Hospital, Bristol. Tetanus. t Thomson, A. T., M.D. F.L.S. Professor of Materia Medica and Therapeutics in the London University. Anthelmintics. Antispasmodics. Astringents. Cathartics. Diaphoretics. Diuretics. Emetics. Emmenagogues. Expectorants. Favus. Herpes. Ichthyosis. Impetigo. Narcotics. Refrigerants. Sedatives. Stimulants. Porrigo. Prurigo. Tonics. Thomson, Thomas, M.D. F.R.S. L. & E. Regius Professor of Chemistry in the Uni- versity of Glasgow, &c. Calculus, (chemical composition.) Waters, mineral. Todd, T. J., M.D. Physician to the Dispen- sary, Brighton. Achor. Acne. Alopecia. Bulls. Ecthyma. Ephelis. Indigestion. Todd, Robert B., M.D. F.R\S. Professor of Physiology and General Anatomy, King's College, London. Paralysis. Pseudo-morbid appearances. Suppuration. Spinal marrow, diseases of. Townsend, Richard, M.D. M.R.I.A. Fellow of the King and Queen's College of Phy- sicians, Dublin. Apoplexy, pulmonary. Atrophy. Emphysema. Emphysema of the lungs. Empyema. Heart, displacement of. Hypertrophy. Rupture of the heart. Tweedie, Alexander, M.D. F.R.S. Physician to the London Fever Hospital, and to the Foundling Hospital. Abscess. Qplic (with Dr. Whiting.) Convalescence. Erysipelas. Exanthemata. Fever, continued. Inflammation, (with Dr. Adair Crawford.) Miliaria. Roseola. Scarlatina. Throat, diseases of the. Watson, Thomas, M.D. Physician to the Middlesex Hospital, &c. Hemorrhage. Whiting, John, M.D. Physician to the Surrey Dispensary, &c. Anodynes. Cold. Colic, (with Dr. Tweedie.) Colica Pictonum. Williams, Charles J. B., M.D. F.R.S. Pro- fessor of Medicine in University College, London. Bronchitis. Catarrh. Coryza. Counter-irritation. Dyspnoea. Expectoration. Incubus. Irritation. Malformations of the heart, Obesity. Pneumonia. Stethoscope. i Venables, R., M.D. London. Liver, diseases of. THE CYCLOPAEDIA OF PRACTICAL MEDICINE. ABDOMEN (Exploration of the)__It is intended, in the present article, to give a brief account of the different methods employed by physicians for exploring, or physically examining, the external parts of the abdomen, with the view of discovering or discriminating the diseases of the viscera contained in this cavity. The term here adopted to designate the application of these methods (from the verb exploro, to examine), although long received into our language, has been only very recently used in medicine in its present sense: it has been borrowed from the pathologi- cal writings of the French. In many parts of the present work occasion will be found of pointing out the paramount importance to the practitioner of a minute and accurate diagnosis of diseases, and of stating, in detail, the various methods in use for acquiring this knowledge. Of these methods none are so certain in their results, and, consequently, so satisfactory to the mind, as those which are based on what are termed physical signs of dis- ease, in contradistinction to the more common class of rational or sympathetic signs which are derived from the more variable phenomena of dis- ease termed symptoms. It is with the physical signs of diseases that exploration, in the sense in which we shall employ it, has to do; and in the present article it is intended to restrict its use to a part only of the physical signs by which abdomi- nal diseases are distinguished. Physicians are often much too negligent in examining the external parts of the body in inter- nal diseases. From inadvertence, carelessness, or mistaken delicacy, they thus deprive themselves of the simplest, readiest, and surest means of re- cognising many important affections. This remark applies chiefly to the diseases of the abdomen and chest, some of which are strikingly expressed, if we may so speak, on the surface—either in a per- manent change of configuration, or in a temporary alteration of the natural movements, or both. Such important physiognomical diagnostics can only be obtained (except in rare cases) by uncovering the body; and they can, in general, be immediately obtained by doing so. It happens constantly to those who are accustomed to examine the surface of the body in internal affections, to meet with examples of important diseases being mistaken or overlooked, merely because this simple proceeding had been neglected by the practitioner. One of the most common cases of this kind is chronic pleurisy, the presence of which is often detected by a single glance at the naked chest; one side being found to be immovable, and either con- Voj.. I___4 c tracted or enlarged beyond the limits of the healthy state. Superficial inflammations of the parietes of the chest and abdomen have been treated aa phlegmasia? of the viscera in persons who had no desire to conceal their complaints ; while others, from unwillingness to admit the existence of local eruptions on the skin, have equally deceived their medical attendants. It is obvious that such mis- takes could not happen to those who are accus- tomed to examine the exterior parts of the body; and it will not be denied that, whenever they do happen, they must tend to lower the character of the practitioner in the eyes of his patient. Such mistakes are much more liable to be made respecting females than males, partly on account of the greater delicacy respecting examination entertained by the physician in the case of the former, and partly owing to the greater obstacles to examination from the peculiar nature of their dress. It will not, we trust, be imagined, from the above remarks, that the writer wishes to recom- mend the examination of the naked chest or ab- domen in every case of alleged disease in these cavities. In most instances, even when a minute investigation is required, it is unnecessary to remove the under garment; and in the case of females this is never to be done if it can be avoided. In some cases, no doubt, it may be expedient to apply the hand to the skin, and even to inspect it freed from all covering; but in the case of females more particularly, neither should be had recourse to, unless an accurate diagnosis cannot be other- wise obtained. If physical examination is of such general im- portance as a means of diagnosis, it is especially so in the diseases of the abdominal cavity. The great number and importance of the organs con- tained in it, render its diseases proportionally numerous and important; while the proximity and intermixture of some of the organs, and the variable site of others, render their symptoms complex and multifarious, and their diagnosis consequently difficult. On the other hand, the abdomen, from its anatomical structure, seems at first sight to promise much greater facilities for the employment of physical diagnosis than either of the two other great cavities of the bo.ly. Its soft and yielding walls at once invite and admit of such examinations of the parts within ts appear to be altogether forbidden by the inflexible bony defences of the others. It will, however, lie seen hereafter, that, in regard to the chest, this superi- ority of the abdomen is only apparent in as far as relates to the certainty of the results; although it (25) 26 ABDOMEN, (EXPLORATION OF THE) is undoubtedly real in respect of the directness and obviousness of the methods of exploration which are applicable to it. Previously to describing these methods, it is necessary to notice the topographical relations of the exterior surface of the abdomen to the parts within. This kind of knowledge is of the great- est importance to the practical physician in regard to many parts of the body, but more particularly the chest and abdomen. Without it he will con- stantly be left in doubt respecting the parts affected with disease, and will frequently be led into the error of attributing the symptoms of one suffering organ to another. With the view of facilitating the acquisition of knowledge of so much value, and of enabling the practitioner accurately to record his own observations, and to communicate to others precise information respecting the seat and signs of internal diseases, it has been custom- ary to map out the exterior surface of the chest and abdomen into different compartments, termed regions, by means of imaginary lines described upon it, corresponding with imaginary planes passing to the centre of the body. These lines have not always been drawn in the same manner : on the contrary, there has ever existed great dis- crepancy among the writers and teachers of this and other countries respecting the number, the extent, and the names of the regions. This is a circumstance greatly to be regretted ; and it is much to be desired that some arrangement could be proposed which might attain general assent from teachers and practical writers. It is probable that no plan can be proposed that is without even obvious defects; but it would be greatly for the benefit of the student and the practitioner if there were a fixed plan of any kind, owe plan universally adopted, even if defective in some of its parts. At present hardly any two teachers or writers adhere to the same division or nomenclature. In the annexed regional plans of the trunk of the body, (designed and executed by Mr. Paxton, of Oxford,) the nomenclature and divisions most generally adopted have been as much as possible adhered to ; but it was occasionally found neces- sary to differ in both these points, in order to attain what appeared to be objects of practical importance. We have gone upon the fundamen- tal principle of defining every region accurately, in every individual case, by drawing all the lines perfectly straight, and between points that are at once fixed in their nature and obvious to the senses. By these means there can never be any doubt as to the intended place or extent of par- ticular regions, whatever objections may be raised against the propriety of the divisions. As it was found advisable to extend the same vertical lines over the two great cavities of the trunk, we are under the necessity of introducing the diagrams of the chest in conjunction with those of the ab- domen, in order to point out the fixed points from which the lines are drawn. We shall only, how- ever, in this place, take notice of the abdominal regions, which, it will be seen, are quite distinct from those of the chest. The various regions are, as we have said, bounded by straight lines, or rather by direct lines drawn between fixed points, on a rounded or uneven surface. The vertical lines which have reference to the abdomen are five in number, and run as follows: 1. from the external tubercle of the pubes (or insertion of Poupart's ligament) to the acromial extremity of the clavicle (right and left side); 2. from the posterior boundary of the axilla (or inferior edge of the latissimus dorsi) to that point of the crest of the ilium, on which it falls vertically (right and left side); 3. along the spinous processes of the vertebrae from the sacrum to the nape of the neck. The transverse lines are four in number, and are drawn exactly in horizon- tal planes, as follows: — l.on the point of the xiphoid cartilage; 2. on the last short rib; 3. on the anterior and superior spinous process of the ilium on each side; 4. on the upper margin of the os pubis. We have thus three horizontal and five vertical bands, and thirteen regions in all; of which five may be termed anterior, four lateral (two on each side), and four posterior. Their names are as follows :—anterior regions, epigas- tric, umbilical, hypogastric, inguinal (right and left) ; lateral regions, hypochondriac (right and left), iliac (right and left); posterior regions, in- ferior dorsal (right and left), lumbar (right and left). We have not carried the subdivision of the inferior zone to the posterior and lateral parts of the trunk ; because the parietes there are of such a nature as to prevent us from deriving any aid in the investigation of the subjacent parts from exploration. There are few more useful exercises for the anatomical student than endeavouring to imprint on his mind some plan of this kind, and to teach himself by observation, and by multiplied experi- ment on the dead subject, the precise relations of the regions to the viscera that lie beneath them. He ought always to consider his knowledge as Fig. 1. ABDOMEN, (EXPLORATION OF THE) Fig. 2. Fig. 3. 27 explanation of the figures. Abdominal Regions. 4. Epigastric. 5. Umbilical. 6. Hypogastric. 9. Hypochondriac. 1. Humeral. 2. Subclavian 3. Mammary. 7. Axillary. 10. Iliac. 11. Inguinal. 15. Inferior Dorsal. 16. Lumbar. Thoracic Regions. imperfect, until he is able to state, with conside- rable accuracy, the organs, or parts of organs, that will be wounded by a stiletto thrust in at any point. It is only after possessing such a degree of knowledge, that he can enter, with full advan- tage, upon the study of the various methods of exploration which we are now about to detail, or that he can expect to derive from them the great practical benefits which they are calculated to supply. The methods of exploring the abdomen may be reduced to three — inspection, manual examina- tion (or palpation), and percussion. We shall notice them in order. I. Inspection. This term is here used in its simplest sense, as restricted to the operations of sight only. By inspection we judge of the size, form, and movements of the abdomen. The two last-named conditions are, perhaps, better ascertained by this than by any of the other forms of exploration. It is needless to point out in how many instances 8. Suhaxillary or Lateral. 13. Scapular. 13. Interscapular. 14. Superior Dorsal or Subscapular. our judgments respecting the nature of diseases, as derived from other signs, are modified by the size of the abdomen. This is an important diagnostic sign in many diseases, both acute and chronic, more particularly perhaps in the diseases of in- fants ; and it is often equally valuable as aiding prognosis, especially in fevers and other acute The mere form of the abdomen, independently of its size, is no less valuable as a sign, in many cases. By this alone we are sometimes enabled to form a probable conjecture, if not to decide at once, respecting the seat and nature of a disease; although a practitioner could not be justified in acting upon such knowledge without having re- course to other signs and other modes of explora- tion. In pregnancy, in ovarian dropsy, in ascites, tympanites, and enlargements of the liver, the form of the abdomen is different. In certain cases, the direction of the inferior border of the ribs assists us in determining whether enlargements of the epigastric and hypochondriac regions origt- 28 ABDOMEN, (EXPLORATION OF THE) nate in the abdomen or within the chest In the former case, we may expect the border of the ribs to be turned outwards; in the latter, inwards, with, probably, a bulging out of the ribs above this point. In some examples of enteritis and colica pictonum, the nature of the pain is very similar; but the form and size of the abdomen are often very different, and sufficient to discriminate the two diseases. In the one the abdomen is distended, in the other contracted. In some of the severer febrile affections of children, the form and size of the abdomen afford valuable signs to assist us in determining a question frequently of great diffi- culty, viz. whether the principal seat of the disease is in the internal mucous membrane or in the brain. The movements of the abdominal parietes are equally worthy the practitioner's attention. In many cases, these movements are characteristic of particular morbid states, and very considerably assist diagnosis, more especially when viewed together with the motions of the thorax. In peri- tonitis, enteritis, and other inflammatory diseases of the abdomen, likewise in great distension of the cavity from dropsy, pregancy, tumours, &c. &c. the parietes frequently remain motionless during respiration, while the movements of the chest are proportionally increased. The reverse obtains in analogous affections of the thoracic viscera. In cases in which both sides of the chest are rendered immovable by pain or physical incapacity, the abdominal movements are often increased to a remarkable extent. This is particularly observed in the case of double pleurisy, and also in asthma. In the paroxysms of this last affection, however, the form and movements of the abdomen are very different from those observed in the former. In asthma, the walls of the chest and the diaphragm are forcibly retracted, and cling to the imperfectly expanded lungs ; the abdominal muscles are also drawn in towards the diaphragm, but are at the same time forced into violent yet very limited action. II. Manual examination, or palpation.* By the simple touch, or application of the hand without pressure, we judge of the size, form, de- gree of sensibility, and temperature, of the exter- na] walls of the abdomen; and by touch, combined with pressure, (palpation,) we attempt to ascertain yet more accurately the condition of the internal organs. For the performance of the former part of the process, no other position of the patient is requisite but that which permits the free access of the hand to the surface of the abdomen ; but for the successful exploration of the internal parts, it becomes necessary that the patient should assume that posture which is most favourable for the relaxation of the abdominal muscles. This result is best obtained when the patient is laid on the back, with the head moderately raised and bent forwards on the breast, the arms extended by the sides, the thighs bent nearly at right angles on the trunk, the knees apart and turned outwards, and the feet resting on the bed in contact with each other. When so placed, the patient should be made to understand that he is to exert as little muscular effort as possible in retaining his posi- tion ; and we are to take care that such exertion * " Palpation, the act of feeling."—Johnsoh. From palpo, or palpor—palpatio. is not forced upon him by any proceeding of ours which can be avoided. Sometimes the mere cold- ness of the hand, or even the simple touch, has the effect of throwing the abdominal muscles into action. Apprehension of pain from pressure has the same effect; and, likewise, misapprehension of our wishes respecting the condition of the ab- dominal parietes. In such cases we shall gene- rally find, after a short time, that the muscles relax gradually of their own accord, particularly if the patient's attention is diverted from our pro- ceedings ; or we succeed in our object by causing the individual to take a deep inspiration, to cough, or speak; by which means the state of tonic tension of the muscles is destroyed. Sometimes, however, we find it impossible to obtain a com- plete relaxation; and this circumstance is of itself an important sign, and taken in conjunction with others is well deserving the attention of the prac- titioner. The patient, in these cases, seems in- stinctively to keep the muscles in a state of tension, in order to ward off the pressure from the parts beneath, some of which are inflamed, and there- fore morbidly sensible. This state of the muscles is often found in inflammation of the intestinal mucous membrane. It is of the more consequence to ensure the complete relaxation of the muscles, because their tension not merely prevents the accurate examina- tion of the parts beneath, but even occasions the muscles themselves to be mistaken for enlarge- ment or induration of the viscera. This remark applies more particularly to the recti muscles, the prominent bellies of which sometimes simulate pretty accurately the inferior border of an enlarged liver. We have often seen this mistake com- mitted at the first moment of exploration; and, although generally, it has not always been cor- rected by further examination. The chief objects we have in view, in exploring the abdomen, are the following :—To ascertain, 1, its form and size; 2, its degree of tension or solidity ; 3, its temperature; 4, its sensibility; 5, the presence or absence of tumours of the viscera, or new growths within the cavity; 6, the presence of fluids in the peritoneal sac; 7, the nature and extent of the intestinal contents, &c Some of these require much more attention than others. We shall only notice, with any degree of minuteness, such of them as are of most im- portance. The form, size, degTee of temperature, tension and superficial sensibility of the abdomen, are ascertained by the simple application of the hand to the different parts of it in succession, or, at most, by the gentlest pressure. Some precautions, however, and some further attention, are requisite, in order to enable us to ascertain the true degree of temperature and sensibility of the parts. Owing to the singular infidelity of our sensa- tions as a measure of temperature, the greatest care is necessary to prevent our being misled in judging of the degree of heat from the testimony of our hands alone. Every body knows that our perceptions of warmth have relation as much to the preceding as to the actual sensation. We are apt to consider a body as warm, solely because it is of superior temperature to one previously touched ; and we may almost immediately be induced to reckon the very same substance cold after touching one that is of a temperature greatly ABDOMEN, (EXPLORATION OF THE) 29 higher. The temperature of the hand itself is also to be taken into account, and not merely its actual temperature, but its habitual temperature. Some persons have hands habitually cold, and others habitually warm ; and it is not likely that such persons will judge similarly of temperature, even when their hands chance to be equally warm at the period of experiment. It is still less likely that they will agree if their hands are of different temperature. In examining the temperature of the abdomen, or of any other part of the body, it will be most safe to judge rather of the relative than of the absolute degree of heat; and this will be best done by examining alternately other parts of the body presumed to be in a state of health.* The temperature of the abdominal surface is frequently an important sign of disease. If very elevated, it indicates inflammation of the subjacent parts, or, at least, that increased afflux of blood, which cannot be practically discriminated from the early stage of inflammation. If that singular, and, we believe, still unexplained pungency, which attends certain febrile and inflammatory affections, is present, the complication renders the sign still more significant of severe disease. In exploring the degree of sensibility, the pres- sure should, of course, in the first place, be made in the gentlest manner, and with the open hand. If the surface is impatient of the slightest touch, we may be assured that the cause of the tender- ness is in the parietes. If no superficial tender- ness exists, we proceed to examine the parts more freely by compressing the parietes more or less forcibly, and in different directions. Sometimes we find that a change in the direction of the pres- sure produces very different results in the same part. In peritonitis, for instance, direct downward pressure towards the spine is sometimes borne tolerably well, when pressure in a lateral direction, particularly such as forces the abdominal peritone- um to slide over the intestines, occasions extreme pain. In chronic diseases, much greater freedom may generally be used in our explorations ; and when considerable doubt exists respecting the nature of a disease, we should endeavour to bring every organ of the abdominal cavity within the sphere of our explorations. Some physicians, in exploring the abdomen, seem to consider it sufficient merely to pass the hand across it once or twice, using a very gentle pressure in the suspected places. Such a method is often more calculated to mislead than to instruct. It may, indeed, satisfy the patient that his case has met with due attention, while he has, at the same time, been treated with gentleness and delicacy ; but it cannot be satisfactory to the practitioner who knows the value of this mode of investigating dis- ease. But while we recommend the propriety of a free exploration, it is necessary to caution the young practitioner against adopting one of unne- cessary violence. Some physicians make use of so much pressure, or rather they apply it in so injudicious a manner, that they hardly ever fail to elicit from the patient the expression of pain in the suspected region. This is particularly the case when the pressure is made, with the very * Nothing can show the imperfection of mere sen- sation as a test of temperature, more strongly than the fact constantly observed, of patients and their attendants reporting particular parts as preternaturally hot—" burn- ing hot,"—which are found on trial, to be of the natural degree of warmth. points, or still more with the nails of the fingers; or when the soft parts are compressed against such as are solid. No very general rules can be laid down in such cases. Experience of the natural sensibility of the parts to pressure, in health and disease, can alone give the true practical tact; but even experience, we find, may here, as in other circumstances, be over-mastered by the influence of theory and prejudice acting on a weak judgment or a warm imagination. In every case, while exploring the sensibility of the abdomen, it is im- portant to watch the expression of the patient's countenance; as this is often found to be a truer index of his sensations than his words are. If, in the course of our exploration, we discover any unusual swelling or indurated part, we must endeavour to ascertain its nature and various relations,— its exact site, size, form, consistence, connexions, and degree of sensibility; whether it contains a fluid or not, whether it is pulsatile or not, and whether it is fixed or movable. All these circumstances are of consequence. The situation, size, and form of the swelling will enable us to judge respecting the organ or part affected ; its consistence, degree of sensibility, &c. will help us to the knowledge of the nature of the tumour itself. In persons that are of a spare habit, and in whom the abdominal parietes are relaxed, and more particularly in women and children, whose muscles are naturally small and feeble, we are able to ascertain the condition of almost all the parts contained in the abdomen with considerable minuteness, and to an extent beyond what is commonly believed by practitioners. In many cases, for instance, it is easy to feel the mesenteric glands when enlarged, and even the kidneys. We must, however, be careful, in making these free examinations, not to mistake natural conditions of the parts for morbid deviations. Masses of in- durated faeces in the colon, and even the spinal column, have been mistaken for morbid growths. (Bianchi, Hist. Haepat. 325. Double, Semeiol. t. i. 383.) Errors of this kind may^n general, be avoided. The movableness of the fscal masses ought to point out their nature ; and the extreme fixedness of the spine, as well as its form and direction, will hardly permit such a mistake to be committed by any one possessed of a common . degree of anatomical knowledge. In examining the abdomen with the view of detecting fluids accumulated in its cavity, we, in some respect, reverse the preparatory steps recom- mended in searching for more solid matters. In exploring for fluids, we wish the abdominal parie- tes to be in a state of tension rather than relaxa- tion : and, with a view to obtain this result, if the patient is in bed, and cannot conveniently get up, we make him lie quite flat, with the head low and the legs extended ; or we even increase the ab- dominal tension still further by placing a pillow under the loins. It is, however, still better if the patient can be placed in the erect position ; as the abdominal walls are thereby rendered naturally tense, and the fluids are accumulated at the inferior and anterior parts of the cavity, in place of being intermixed with, and in some degree hidden by, the intestines, as is partly the case when the patient is in the horizontal position. The little manoeuvre for ascertaining the fluctuation of the fluid is universally known. It consists, simply, in placing the palm of one hand against one side of 30 ABDOMEN, (EXPLORATION OF THE) the abdomen, with a firm but gentle pressure, and tapping smartly with the other hand directly op- posite to it on the other side. If fluid is present, the impulse will be transmitted through it to the other hand, producing a peculiar vibratory shock which cannot be mistaken, after having been ex- perienced a certain number of times. The import of this fluctuation as a sign of disease is well known : it is almost pathognomonic of ascites, or dropsy of the peritoneum. It is, however, also found in other diseases of the abdomen ; and is generally acknowledged to be of importance, both positively and negatively, in aiding their diagnosis. For the various diseases in which it is employed as a sign, we refer to the different articles of this work, in which these diseases are treated. And we would here observe once for all, that in drawing up the present paper we have always had in view the ampler diagnosis which will be found under the head of individual diseases; our object not being to establish the diagnosis of particular dis- eases, but to give the practitioner a general out- line of the methods of exploration which are more or less applicable to all the diseases of the abdomen. If this were the place for such disquisitions, it were easy to show, from the authority of the best practical authors of all ages, how very important a place in the diagnosis of diseases has been always assigned to the physical exploration of the abdo- men. In the early ages of physic, this practice was, from various circumstances, much more in use than afterwards. Subsequently to the discovery of the circulation of the blood, when so much reliance was placed on the indications of the pulse, and when men's minds were so much occupied by theoretical and metaphysical distinctions, the phy- sical investigation of diseases generally, and of those of the abdomen among the rest, fell into neglect. It has, however, during the last fifty years, and more especially during the present century, more than regained its pristine estimation with all well-informed physicians, and is at length secured from ^11 future decadence on the immov- able basis of organic pathology. With good reason, therefore, we may conclude this imperfect exposition of the method of palpation, as applied to diseases of the abdomen, in the words of Hip- pocrates and Baglivi. " Certain it is that he who examines the abdomen, as well as the pulse, is much less likely to be deceived than he who does not."* " If physicians were always to examine the abdomen, upon first visiting the patient, more particularly in acute diseases, they would assuredly commit much fewer mistakes than they do at present, neglecting this method of exploration. The knowledge of the condition of the upper parts of the abdomen improves vastly both our treat- ment and our prognosis."j- III. Percussion. (From percussio—percutio —per and quatio.) This form of abdominal ex- ploration had been used as an occasional aid to diagnosis from very early times. The manoeuvre for detecting the fluctuation of liquids, mentioned * Deindequi manibuscontrectavit ventrem [ac venas], minus falli potest, quam qui non contrectavit. Hippoc. Predict., lib ii., § v. f Si inedici nostri temporis omnium a>grotorum hypo- chondria statim tractarent, in morbus potissimuin acutis, pauciorescertecomniitterenterrorpsqiiani faciuutspreta hypochondriorum observatione. Qui bene noverit hypo- chondriorum statuin in morbis, quam bene curare nove- rit, quam bene prsesagire! Baglivi de Prax. Med., lib. ii., cap. 9. Op. p. 39. under the last head, is a mode of percussion ; and the very name so long borne by one morbid con- dition of this cavity (tympanites, from ™/nraw», a drum) is at once sufficient evidence of the prac- tice, and of its antiquity. It is only, however, of very recent date that any attempt has been made to establish a formal and elaborate system of dia- gnosis, applicable to diseases of the abdomen, by means of percussion. M. Piorry,a young Parisian physician, has the honour of having, if not in- vented, at least brought into a formal and matured shape, this new application of the discovery of Auenbrugger, and with practical results of greater precision and importance than could have been anticipated.! In the article Auscultation a full account will be given of the principles upon which per- cussion, as a general means of diagnosis, is founded. At present, nothing more will be attempted than a mere practical exposition of the method as applied to the discrimination of abdominal dis- eases. We shall only so far anticipate the details of the article referred to as to state that there are two methods of eliciting sounds from the surface of the body by percussion, with the view of judg- ing of the physical condition of the parts beneath, — the one termed direct percussion, or, simply, percussion ; the other mediate percussion. The former is the proceeding proposed by the great discoverer of the method, Auenbrugger, and con- sists in simply striking the part in a particular manner, with the points of two or more fingers united ; the latter differs very little either in prin- ciple or practice, except that a thin plate of solid and elastic matter, as of wood or ivory, is inter- posed between the fingers and the surface of the body. In exploring the chest by means of per- cussion, the comparative solidity and elasticity of its walls, as well as the nature of its contents, tender the interposition of a sonorous body be- tween the fingers and its surface less necessary, although it will be seen that this is uSeful even there; but in the case of the abdomen such assist- ance is absolutely necessary to the production of sufficient sound to enable us to judge of the con- dition of the viscera within. In the following observations it will, therefore, be understood that mediate percussion is the method always spoken of. The small ivory plate on which the percus- sion is made has been termed, by its inventor M. Piorry, the pleximeter, or measurer of percussion. In exploring the abdomen by this method, we make use of various degrees of force in applying the plate to the surface, so as to depress this more or less, according to the objects we have in view. Ill many cases percussion on the plate pressed slightly on the surface, yields a very different sound from that elicited from it in the very same spot, when it is pressed deeply into the cavity of the abdomen. In the former case, the sound may be perfectly tympanitic, owing to the proximity to the surface of the intestines containing air; while in the latter it is often dull or dead, from the circumstance of the plate having been depressed below the level of the floating intestines into mediate contact with some solid or fluid body incapable of yielding similar sound*. J The two following works, by M. Piorry, are well worthy the reader's attention : — 1. De la Percussion Mediate. Paris, 1828. 2. Du Procede Operatoire a suivre dans I'Exploration des Organes par la Percussion Mediate. Paris 1830. ABDOMEN, (EXPLORATION OF THE) 31 In the following brief sketch of the results of abdominal percussion, we shall, in a great mea- sure, follow M. Piorry, referring the reader to his elaborate work for further information. It will scarcely be credited, by those who have never practised, nor seen practised, this method, to what a singular degree of minuteness of diagnosis M. Piorry has carried it. Such persons may proba- bly be disposed to consider many of his statements as founded in delusion, if not in fiction. But it may be well for them to recollect that the discove- ries of Laennec were so designated by many on their first promulgation ; while, at present, within the short period of a dozen years, only an insig- nificant minority call in question the truth of even the most remarkable of them. We do not pretend to have verified all the statements made by M. Piorry ; and, indeed, nothing short of the indomi- table zeal of a young Parisian pathologist of the present day could enable any one to do so within a moderate space of time ; but from our knowledge of the results that are obtained from percussion as applied to the chest, and from numerous trials of it in abdominal affections, since the publication of M. Piorry's first work, we entertain no doubt of the general accuracy of his conclusions. At the same time we must admit, that to reach such a nicety of acoustic tact as is implied in several of the results recorded by him, will require more leisure and continued application than most men engaged in practice can afford to give. But such a practical acquaintance with the method as will be found highly useful, may soon be acquired by any one ; and we consider it the duty of every practitioner to endeavour to acquire thus much at least. . The position of the stomach relatively with the surface is well known. In general, it occupies the epigastric and left hypochondriac regions, its greater extremity occupying the latter, and its smaller extremity extending to the right side of the epigastric region, or even into the superior part of the right iliac. But its position varies extremely, according to its degree of fulness, and the condition of the neighbouring viscera. It varies also greatly in respect of its proximity to the abdominal parietes. In the great majority of cases, some part of its surface lies in immediate contact with the abdominal parietes, more espe- cially when it contains a considerable quantity of ingesta. When empty, or nearly empty, it some- times is retracted towards the spine, while the colon or ilium lies in the front of it. As the stomach very generally contains a considerable portion of air, percussion over its usual site com- monly yields a very clear sound. The clearness of this sound is found to be gradually diminished as food or drink is taken. When the stomach is filled to repletion, it yields nearly as dull a sound as the solid viscera. When it contains, at the same time, a considerable quantity both of air and liquid, percussion produces a peculiar sound, termed humoric by M. Piorry, and which has a sort of silvery, vibratory clearness, somewhat resembling the metallic tinkling of Laennec. This sound is observed in other parts of the abdomen, where there is an accumulation of air and liquid either in actual contact or in contigu- ous cavities. It is not, however, peculiar to this condition of parts, being also found wherever the air is forced out of a large cavity through a small opening. The knowledge of the condition of the stomach, as to emptiness or repletion, and likewise as to the general quality of its contents when full, may be very useful in many cases, both in prac- tical medicine and in medical jurisprudence. When we know, from the history of the case, that the viscus is empty, or, at least, that it does not contain any food, a completely dull sound elicited from its usual site will indicate that some conside- rable morbid change has taken place either in it or the neighbouring parts. Its habitual tympany will be manifested by signs of an opposite kind. In the state of health, the large intestines almost always contain a very considerable quantity of air : the small intestines generally contain some also. In consequence of this circumstance, per- cussion over their respective sites yields the tym- panitic sound in a greater or less degree, in pro- portion to their proximity to the surface, the size of the intestine, and quantity of air contained in it. The coecum being one of the most fixed parts of the intestinal canal, and generally containing a considerable quantity of gas, renders the right iliac region usually sonorous in the state of health. From this point we can also, in general, trace the transverse arch of the colon, by means of a tract of clearer sound across the upper part of the um- bilical region to the left iliac region. It is well known how constantly this intestine contains a large quantity of air. The left iliac region gene- rally yields a duller sound than the right, but not always ; the result being dependent on the parti- cular portion of intestine lodged there, and the state of its contents. The sigmoid flexure, which most commonly occupies this region, contains, in general, more fecal matter than the coecum or the transverse arch of the colon, and therefore yields a duller sound. The small intestines usually occupy the greater part of the centre of the abdomen, filling the umbilical region, and encroaching, more or less, upon all the adjacent regions. They may be said to be, in a considerable degree, surrounded by the colon. They generally contain some air in the state of health ; but a great deal less in proportion to their size and other fecal contents, than the large intestines : they, therefore, yield much less sound on percussion. When they contain ver little air and much chymous fluid, they hardl; give any of the tympanitic resonance. This natural dulness is sometimes increased by disease within the bowel, but it is, we believe, much more frequently diminished. The increased dulness in the regions occupied by the sonorous portions of the intestines is most commonly occasioned by disease external to their canal. In affections of the mucous membrane, a morbid augmentation of the quantity of gas usually contained in the bowels is much more common than a diminution of it. In many cases, the intestines are extremely distended with gas throughout the greater part of their whole course; and when this distension is of some continuance, it has been frequently described as a distinct disease, under the name of tympanites or tympany, from the drum-like tension of the abdomen produced by it, and the loud sound elicited on percussion. It is obvious that a practitioner, well acquainted with the various kinds and degrees of sound usu- ally elicited in health from the regions chiefly occupied by the hollow viscera, may derive much 32 ABDOMEN, (EXPLORATION OF THK) important information calculated to aid his diag- nosis and prognosis, and to regulate his practice, by attending to the modification of those sounds produced by disease. In relation to this point, it suffices to notice the different judgment that will be formed in two cases having the same degree of swelling, but with the sound quite dull in the one, and tympanitic in the other. When the bladder of urine is at all distended by its natural contents, so as to project beyond the edge of the pubes, its presence may always be easily ascertained by percussion. It yields a dull sound, like that of ascites, which contrasts well with the clear intestinal sound on all sides of it, but is yet of a different character from that yielded by a solid tumour. M. Piorry assures us that it is even possible to ascertain the presence and dimensions of the gall-bladder by the same means. We have never attempted to verify this statement. The presence of the solid viscera and of solid growths of a morbid kind is ascertained chiefly by the contrast of their dull sound with the resonance of the intestines around. It is, there- fore, important to be well acquainted with the natural seat and limits of these viscera in the state of health. In judging of morbid states of the liver, suf- ficient allowance is not always made for varieties that occur in its position, independently of any disease in the organ itself. Disease of the right cavity of the chest will occasion retraction or depression of the liver, according as it is of a kind to elevate or depress the diaphragm. Dis- eases of the abdomen will have the same effect by a reverse operation. Alteration of the shape of the lower part of the chest from the effects of stays, sometimes occasions a remarkable change in the relative position of the liver as well as of the stomach. From this cause the liver is some- times completely hidden beneath the compressed border of the thorax ; at other times its left lobe is thrust before the stomach into the left hypo- chondriac region, or depressed into the umbilical. Besides, the size of the liver varies considerably in different persons, and in the different periods of life. In the majority of healthy and well formed persons, its lower border scarcely descends below the margin of the ribs, or encroaches upon the scrobiculus cordis. The situation and size of the liver, both in health and disease, are well ascertained by percussion. It is bounded by the stomach on the left side, and the colon below, both generally containing air ; and it is accurately bounded above by the lungs, always, in health, full of air : it lies, therefore, yielding its dull sound, in the midst of a sonorous region. If the practitioner is well acquainted with the ordinary size of the healthy organ, and takes into account all the circumstances that can influence its posi- tion in the individual case before him, he will not often be mistaken respecting the actual size of the liver, nor have much difficulty in determining whether this size is to be considered morbid. Manual examination will here be of great value, as far as respects the inferior or abdominal border of the liver; but percussion and auscultation can alone point out the upper limits of the viscus.* * It is impossible to notice every peculiarity of disease that may interfere with the manifestation of the usual Bounds of health; or to lay down rules of diagnosis The situation of the spleen being a good deal dependent on that of the stomach, is less fixed than that of the liver; still, generally speaking, it may be said to be placed in the left superior dorsal region immediately below the diaphragm, and a little to the left of the spinal column. It is entirely covered by the ribs. Being surround- ed on all sides, like the liver, by hollow viscera containing air, (except when it adjoins the kid- ney,) it would be very easily distinguishable by percussion, if it were placed as close to the exterior of the body as the liver is. But this is not the case; and we cannot, therefore, expect either the same distinctness in our signs, or accu- racy in our diagnostics, here, as in percussion of the hepatic region. Still, there can be no doubt that when the spleen is enlarged so as to displace the floating viscera, and approach the side, its presence may be readily recognised. M. Piorry, indeed, says that its exact site may be ascertained, in most cases, even in health. The kidneys are usually seated about the mid- dle of the inferior dorsal region, on a level with the last dorsal and two upper lumbar vertebrae. Being separated from the surface by the thick mass of the lumbar muscles, it is hardly to be expected that their place should be indicated by percussion ; and we confess that we never made the experiment. If this accuracy of diagnosis were attainable, we are somewhat doubtful if it would be of any use. Still M. Piorry assures us that, both in health and disease, percussion is capable of making known the position of the kidneys, when exercised with certain necessary precautions detailed by him. In no morbid condition of the abdominal cavity are the results of percussion more satisfactory than in the case of liquid effusions into the peri- toneum. In most cases, either inflammatory or simply dropsical, the effused fluids seek the low- est level, according to the position of the patient, leaving the hollow viscera, containing air, to float partially above them. Over the space occupied by the latter, percussion will, of course, elicit the tympanitic resonance; while over that occupied by the denser liquid, the sound will be compara- tively dull or dead. In general, the demarcation of the sonorous and dull regions is very abrupt and distinct; and is proved, by experiment, to applicable to every such peculiarity. While engaged in writing the preceding remarks, we met with an instance of this sort, in the case of a man affected with ascites and anasarca. In this case, the liver was evidently very small, at least in its interior portion, because percussion elicited the clear tympanitic sound over all the border of the ribs and for a couple of inches above this. It was also evident that there was no accumulation of water in the chest, at least to any extent; and there existed no sitrn of pulmonary disease. On the lower part of the right side of the chest, above the usual site of the liver, there was, however, a space of three inches broad, in- cluding the nipple, and stretching laterally to a consider- able extent, which yielded a perfectly dull sound. Was this the liver stretching so high into the thorax? or was it a tumour attached to the diaphragm ? Dissection ex- plained the difficulty at once. It appeared that this man on some former occasion had had lntlamination of the peritoneal coat of the upper face of the liver, wliich had terminated in partially attaching the viscus to the dia- phragm in such a way as to form, by the adhesion, a shut but empty sac between the peritoneal coats of the liver and diaphragm. On the supervention of the drop- sical disposition, this portion of the serous membrane threw out its serum like the rest; but having no outlet, it accumulated ; and rinding the diaphragm more yield- ing than the liver, it thrust the former upwards into the chest in the form of a tumour. The sac coutamed near- ly a pint of serum. ABORTION. 33 be always that of the temporary level of the fluid. Change of position immediately alters the rela- tive positions of the dull and tympanitic regions. For example : in the case of a moderate accumu- lation of fluid, when the patient is in the erect position, the whole of the lower parts of the abdomen, viz. : the hypogastric, inguinal, and part, at least, of the epigastric, iliac, and inferior dorsal regions, will yield the dull sound ; but if the patient assumes the horizontal posture, all the anterior regions will resume the tympanitic re- sonance, while the dulness will be transferred to the whole of the lateral and dorsal regions. The degree of dulness of sound is found to be in- creased in proportion as the percussion is made low down in the regions containing the fluid. It was formerly stated that, if in cases of moderate effusion we press the plate forcibly upon the abdomen, we frequently reach a point where per- cussion elicits a dull sound, although it had elicited a clear sound from the same spot when the plate was only pressed gently upon the sur- face. The fact is explained by the pleximeter having in the former case reached the level of the fluid in the abdominal cavity, after displacing or compressing the hollow bowels which had been floating above it. These various results indica- tive of the presence of fluid are frequently obtain- ed when the quantity is so small as to be undis- coverable by fluctuation. As they are equally observed whether the effusion is the consequence of inflammation or simple dropsy, they will be found in most cases of peritonitis ; and, therefore, percussion will prove, not merely a diagnostic of this disease, but a valuable aid in discriminating it from enteritis, properly so called. In inflam- matory affections of the abdomen, it is necessary to be very gentle in our operations on account of the painful state of the parts ; and, in such cases, it may be further requisite to employ a broader plate, with the view of diffusing the pressure more equably over the tender parts.* In the encysted dropsy of the abdomen, the results of percussion are, in several respects, dif- ferent ; and the differences supply means for enabling us to distinguish the two affections. In the encysted dropsy the sound is much duller ; the fluid not being able to change its place, the sphere of dull sound is almost fixed; or if the whole cyst changes its place, which it sometimes does in different postures of the patient, the hydrostatic line of level is never formed as in the case of the loose effusion. In these cases, also, we frequently find the tympanitic resonance beneath the cyst, which could not be the case in simple ascites; and the line of demarcation be- tween the dull and sonorous regions is seldom quite straight, as in the last-named disease. It is hardly necessary to caution the reader that, in all these cases, no one should be so imprudent as * M Tarral has recently described a new mode of detecting abdominal effusions, which he terms superficial fluctuation, (fluctuation peripherique). His description of it is as follows : " Place both hands on the abdomen, two or three inches apart, and with the two fore-fingers parallel to each other; then, while the hands are still in this position, give slight blows or shocks on the abdomi- nal parietes with the fore-finger of the right-hand : this will produce an undulatory motion in the effused fluid, which v ill he readily perceived by the fore-linger of the left-hand. The Mine result i-. obtained, if the right- hand is quite raided, provided the blows are given ob- liquely as if brushing the surface."—Piorry, du Procedi Operatoire, p. 1:17. Vol. I. —5 to trust to percussion alone in forming a diag- nosis. In all kinds of cysts, as well as in other tumours, developed among the floating viscera, palpation will be, at least, of equal value with percussion. There are, indeed, few cases, if any, in which the one should be employed exclusively of the other, in the investigation of abdominal diseases. In the case of solid tumours, as of cysts, when they approach the surface, and thereby displace the floating viscera, they yield the dull sound on percussion. When seated more profoundly, the dull sound is only obtained by depressing the abdominal parietes to the level of the solid mass. Percussion is sometimes productive of the best results in cases of indurations and tumours of the abdominal parietes, such as chronic abscess in the interstices of the muscles. In such cases it is sometimes difficult to decide, especially in fat persons, whether the tumour has its seat within the cavity ; and here we have found percussion afford great aid in removing the difficulty. When the tumour is seated in the parietes, percussion, when applied with sufficient force, will elicit the clear sound, however solid the tumour may be, if it is not of much greater size than is usually the case in such instances. In a solid tumour, spring- ing from within the abdomen itself, and pressing against the parietes, the sound will be perfectly John Forbes. ABORTION, (abortus,) signifies the expul- *^' sion of the foetus from the uterus before its dif- ferent organs have been sufficiently developed to enable it to support an independent life. When the product of conception is expelled between this period and the full term of utero-gestation, the process is usually termed premature labour. Abortion is a frequent occurrence in the early months of pregnancy, particularly among women of the lower classes of society, who are exposed to much bodily fatigue and mental anxiety. [Dr. Collins, of Dublin, met with 293 prema- ture cases in 16,414; and Dr. Beatty, with 21 premature cases in 1200. Dr. Churchill records 65 cases of abortion in 1705 deliveries; Madame Lachapelle, 116 cases in 21,960; and M. Deubcl, 35 in 420 ; making, in all, 530 premature cases in 41,699 deliveries, or 1 in 78$. It has been sug- gested by Dr. Guy as probable, that the small proportion observed by Madame Lachapelle is owing to the fact, that the females, who came under her observation at La Maternite, were in the latter months of pregnancy, when abor- tions arc comparatively rare ; and the same ex- planation may apply to other cases.] It is most liable to occur in plethoric, irritable, and nervous subjects; in women who are affected with con- stitutional diseases, more especially syphilis ; in those who have deformity of the bones of the pelvis, or some organic disease in the uterine organs. All the chronic diseases, therefore, to which the uterus and its appendages are liable, may be considered causes of abortion. The pro duction of polypi in the cavity of the uterus, or of fibro-cartilaginous tumours in its walls, and morbid adhesions of the uterus to the surround- ing viscera, may all, by impeding the regular enlargement of the gravid uterus, give rise to premature expulsion of its contents. Other predisposing causes of abortion, though 34 ABORTION. less evident than those now enumerated, are also usually admitted by authors : for example, leu- corrhcea, irritability or too great contractility and rigidity of the uterine fibres and blood-vessels. Those who have insisted on rigidity of the uterine fibres as a cause of abortion have been led into error, by supposing that the uterus enlarges during pregnancy by the mere force of the mechanical distension of the ovum, and not by the gradual developement of all the textures of the organ, in exact correspondence with the growth of the organs of the foetus. But by far the most frequent cause of abortion is in the product of conception itself; viz. in a diseased condition of the fcetus, or its involucra, by which it is deprived of life, and afterwards expelled from the uterus like a foreign body. The blighted ovum is thrown off from the parent, as fruit which has become withered is separated from the branch of the tree on which it has been pro- duced. We have examined numerous ova which have been prematurely expelled, and in many of these, where no disease was obvious at first, some morbid state of the membranes, placenta, or em- bryo itself, has been detected, sufficient to account for the accident, wholly independent of any con- stitutional or local affection of the mother. Some- times the chorion has been thickened, opaque, and extremely irregular, or lobulated, on its internal surface. The amnion, in some cases, has under- gone similar changes, so that the healthy appear- ance of the involucra has been entirely lost. A collection of serum, or blood, has not unfrequently, also, taken place, between the chorion and amnion. The placenta, in some cases of abortion after the third month, has been hard, like cartilage, small and imperfectly formed, with calcareous particles deposited in its substance : in others, the placenta has been unusually large, and its vascular struc- ture has been changed into a soft yellow fatty substance ; or hydatids have been developed in its tissue. The umbilical cord, in these instances, has been remarkably slender, and the foetus has appeared to perish for want of a proper supply of nourishment ; and not from any defect in the organization of its internal parts. The brain of the foetus, or the thoracic or ab- dominal viscera, may all undergo various altera- tions of structure incompatible with life; and where the life of the fcetus is extinct, it becomes an extraneous body ; expulsive efforts on the part of the uterus are usually soon set up, and abortion ensus as the necessary consequence. When the ovum is healthy, it adheres to the uterus with great force ; but when diseased, the slightest shock to the mother, the most trifling mental affliction, is sufficient to cause it to be expelled. Women have had the bones of the extremities fractured during pregnancy, and have suffered other grievous injuries, without miscarrying. A woman men- tioned by Mauriceau escaped by a window from the third floor of her house when on fire, and in her fall to the ground fractured her arm, yet abortion did not follow. The case of a young woman with a narrow pelvis is related by Madame Lachapelle, who threw herself into a deep pit, and suffered injuries of which she subsequently died, yet the foetus was not expelled. All cases of abortion cannot, however, be referred to organic diseases of the uterine organs, or of the embryo and its involucra ; since it can- not be doubted that the process often arises from accidental detachment of the placenta, in conse- quence of an unusual determination of blood to the vessels of the uterus, or contraction of its parietes. The placenta adheres to the uterus by means of the deciduous membrane alone, which is directly applied to the openings of the uterine sinuses. If the impetus of the blood in these be increased by an excited state of the general circu- lation, or by irritation of the uterus itself, an unu- sual afflux of blood to these vessels will take place, and the placenta will be forced from its connexion with the uterus, more or less exten- sively, by the extravasation of blood from the openings of the uterine sinuses, between the placenta and uterus. If this takes place to a con- siderable extent, the process of gestation will be arrested, and in a longer or shorter period the ovum will be expelled. In plethoric women, or in those who menstruate copiously, very slight causes may give rise to a hemorrhagic effort in the uterine vessels, and to the extravasation of blood between the uterus and placenta, with the other consequences now described. A plethoric state of the uterine organs is most frequently met with in those who lead luxurious lives, who sleep in warm soft beds, and indulge to excess in animal enjoyments. This plethoric state of the uterus commonly gives rise to a sense of weight in the hypogastric region, or irregular pains of the uterus; but it sometimes happens that the blood suddenly bursts from the uterine vessels, and detaches the placenta, where there has existed no previous sign of unusual determination of blood to the parts. Besides these causes, there are others which excite undue determination of blood to the uterine organs, as violent exercise, dancing, the use of the warm bath, the employment of acrid cathartics and emetics, spontaneous diarrhoea, the irritation of hemorrhoids, injurious pressure of the hypogas- trium, and violent passions of the mind. Opening the membranes of the ovum and evacuating the liquor amnii certainly gives rise to premature expulsion of the contents of the gravid uterus. [Occasionally a habit of aborting is acquired ; so that it is extremely difficult for the female to pass the period at which the accident has occurred in previous pregnancies. Cases have occurred in which it has happened upwards of twenty times in succession, about the same period of gestation.] The symptoms which precede abortion will be greatly modified by the exciting cause. For the most part, the expulsive process is preceded by unusual depression of strength and spirits; by attacks of faintness, sense of coldness in the pelvis, palpitation, flaccidity of the breasts, a disordered state of the stomach and bowels, and other symp- toms, which indicate that the embryo has been deprived of life. Where an unusual afflux of blood to the uterus is the cause, the uterine pains or contractions are usually preceded for some days by rigours, lassi- tude, heat of skin, thirst, loss of appetite, excited state of the circulation, and sense of weight in the pelvis and loins. A greater or smaller quantity of blood then escapes from the uterus and vagina, with pains occurring at intervals, like the pains of natural labour. Where the discharge of blood is great, the placenta has usually been extensively detached from the uterus, and all efforts to prevent ABORTION. 35 the establishment of contractions are consequently unavailing. In some cases, where a considerable hemorrhage has taken place, with irregular pains, in the early months, the hemorrhage and contrac- tions have both been suspended by the remedies employed, and the fetus has been retained until i the full period. In no case, however, has the pro- gress towards the complete expulsion of the ovum been averted, where the pains have recurred at regular intervals, with discharge of blood from the uterus, or a certain quantity of a dark-coloured serous fluid, with softening of the os and cervix uteri, and the formation of the bag of waters in the mouth of the uterus during the pains, have taken place. Under such circumstances, all our efforts to prevent abortion will prove wholly inef- fectual. When the embryo is dead, it is often expelled in a short period, with little pain and trifling loss of blood ; in other cases the process is very pro- tracted, continuing many days; and in some rare cases which have been reported, the ovum, after having been retained in the uterus many months, has passed through various stages of putrefaction or decomposition. The embryo may die before the end of the third month, and not be expelled till the fourth or fifth month ; or a foetus of seven or eight months may lose its vitality, and not be expelled till the full period of gestation is com- pleted. In twin cases one foetus may die in the latter months, and be retained until the full period, and then expelled with the living child. It has been supposed that the embryo may be expelled, and yet the membranes continue to adhere to the uterus, and be completely developed. The membrana decidua is said to acquire a con- siderable thickness, and the amnion entirely to disappear, while the cavity of the chorion gradu- ally contracting, the mass which remains is only a red fleshy substance, in the centre of which there is sometimes visible a small serous cavity. M. Velpeau and other French pathologists have explained the formation of fleshy moles on this principle, but their opinion is not supported by satisfactory proof; for though these substances are invariably the products of conception, it is not certain that they are formed by the growth of the membranes subsequent to the death and expulsion of the embryo. In several cases of this descrip- tion no embryo was at any time discharged. Treatment.—In premature expulsion of the ovum from organic disease of the uterine organs, or from alterations of structure in the embryo or its involucra, any plan of treatment is not only inefficacious, but even injurious, where the con- tractions of the uterus have been excited to throw off its morbid contents. Where the symptoms of abortion come on without any apparent cause, we have reason to fear that they arise from this state of the uterus or its contents. The treatment must be directed to the following points : first, to pro- cure a complete separation of the ovum ; secondly, to moderate the hemorrhage and pain which may accompany it. By removing plethora, where there is general fulness and excitement, by venesection, and by calming the violence of the uterine contractions by sedatives, we shall often prevent a protracted discharge of blood ; and by obtaining relaxation of the os and cervix uteri, favour the complete escape of the ovum. -Where there are no signs | of local or general plethora and excitement, blood- letting is contra-indicated. In threatened abortion from congestion of blood, or unusual determination of this fluid to the ute- rus, with slight detachment of the placenta, and irregular uterine contractions, it is possible in some cases, by the prompt application of remedies, to arrest the mischief. The greatest mental tran- quillity, and absolute rest in the horizontal posture, on a mattress or couch, with the body lightly covered, should be enjoined in all cases of threat- ened abortion of this description. If the patient is plethoric, and the pulse accelerated, blood is immediately to be detracted, in quantity propor- tioned to the urgency of the symptoms. Twelve or sixteen ounces should be taken from the arm, and, if necessary, the same quantity should again be taken after a time. Cold applications, and even ice, if it can be procured, should be applied over the pubis. A dose of laudanum, or liquor opii sedativus, is to be given, or a starch and laudanum clyster may be administered, to prevent or quiet the uterine contractions. The acetate of lead is in these cases a valuable remedy. Two grains, combined with a quarter of a grain of opium, may be taken every three hours until the discharge of blood begins to abate. [Should the flooding be excessive, the tampon should be had recourse to. This may consist of a piece of soft sponge, of sufficient size, which may be introduced in the dry state, or, lubricated with oil or melted lard. It favours the formation of a coagulum, and the consequent arrest of the hemorrhage. When any portion of the ovum is retained in the uterus, it is recommended by Dr. =?\ Dewees to employ a wire crotchet, as 1 represented in the marginal figure, which is one-third of the proper size. It con- sists of a piece of steel, of the thickness of a small quill at its handle, and gradually tapered off to its other extremity, which is bent to a hook of small size. When the placenta is felt to be embraced by the neck of the uterus, the crotchet may be used in the following manner. The fore-finger of the right hand is placed within, or at the edge of the os tincse ; and with the left the hooked extremity is conducted along this finger, until it is within the uterus. It is gently carried up to the fundus, and then slowly drawn downwards, which causes the curved point to fix in the placenta. J It may then be withdrawn, and the pla- 9centa with it. In every case in which Dr. Dewees used it, the discharge in- stantly ceased. Dr. Bond, of Philadelphia, has contrived a forceps, with the view of supplying the acknowledged defective means, in present use, for the removal of the placenta in cases of abortion attended with uterine hemorrhage. The forceps is about ten inches long, curved laterally upon a radius of about twelve inches—the handles being four inches, and the blades about six inches in length. The blades terminate in an elliptical expansion, about an inch long, and three or four eighths of an inch wide, without any fenestra. The handles and blades, including the expanded part, are bevelled or rounded off, so as to avoid the risk of wounding or pinching any of the soft 36 ABSCESS, (INTERNAL) parts. Within this rounded edge, the expanded part is made very rough, so as to maintain a secure hold upon the body embraced. The forceps may be made straight; but Dr. Bond thinks, that in most cases the curved instrument will be found more convenient for the operator and easier for the patient] As to the subsequent effect of abortion, it may be stated as a general fact, that, in a very large proportion of cases, it produces little or no inju- rious effect on the constitution of the mother. It is an accident of very frequent occurrence in all countries, and has often occurred without leaving any permanent injury. Where the process of expulsion has been protracted, and much blood has drained from the uterine vessels, a proportional injurious effect has been the consequence on the general health of the mother. From what has now been stated respecting the causes and treatment of abortion, little requires to be said as to the management of women who are habitually liable to this accident. We are in possession of no means which can either prevent or remove the numerous organic diseases of the uterine organs, and of the embryo and its involu- cra. Much, however, may be done to avert the danger where it arises from plethora and irritation of the uterus alone, by obviating general fulness, and taking off the suceptibility to premature con- traction of the uterine fibres, by rest, mild diet, and the occasional use of anodynes. Where there is much constitutional debility present, we must adopt all the means we possess for relieving the weakness, and more particularly the cold bath, and proper diet and exercise. Warm rooms and late hours are to be avoided. [Dr. Churchill, considers, that one of the most effective means for breaking in upon the habit is to give the uterus a long rest, by separating hus- band and wife for several months ; and Dr. Hus- ton places great stress on the use of opiate injec- tions daily, with continuance in the horizontal posture. By these means, a tolerance on the part of the uterus has been acquired, which has allow- ed the gestation to go on until the full period.] The practice of inducing abortion for criminal purposes has prevailed in all ages. In the early months it is extremely difficult, from the appear- ances in the mother, to ascertain with absolute certainty that abortion has taken place. In dysmenorrhea there are, sometimes, membranous substances thrown off" from the inner surface of the uterus which strikingly resemble the products of conception ; and even if the uterine organs are examined, we shall not arrive at complete certainty on the subject. Blood-letting, acrid cathartics, diuretics and emmenagogues, cantha- rides, the juniperus sabina, and various local means, have been employed to excite premature expulsion of the embryo. By the Ellenborough Act, passed in 1803, it was ordained in this coun- try, " that if any person shall wilfully administer, or cause to be administered, any medicine, drug, or other substance or thing whatsoever, or use, or cause to be used or employed, any instrument, &c, with intent to procure the miscarriage of any woman not being, or not being proved to be, quick with child, at the time of committing such thing, or usin^ such means, then, and in every such case, the person so offending, their counselors, aiders, and abettors, shall be and are declare! guilty of felony, and shall be liable to be fined, imprisoned, set in and upon the pillory, publicly I or privately whipped, or transported beyond the | sea for any term not exceeding fourteen years. The same act ordains that administering medi- cines, drugs, &c, with the intent to procure abor- tion, after quickening, shall be punishable with death. [The absuTd distinction between quick and not quick with child, which is still adhered to in the laws of some of the States, has been abandoned in England, in a more recent statute — 1 Vic- toria, cap. 85. The following is the law as it now stands : « And be it enacted, that whoso- ever, with intent to procure the miscarriage of any woman, shall unlawfully administer to her, or cause to be taken by her, any poison or other noxious thing, or shall unlawfully use any in- strument, or other means whatsoever, with the like intent, shall be guilty of felony, and being convicted thereof, shall be liable, at the discretion of the court, to be transported beyond the seas for the term of his or her natural life, or for any term not less than 15 years, or to be imprisoned for any term not exceeding 3 years."] iS^ Robert Lee. rABSCESS, Internal---The term abscess (derived from abscedo, to depart, denoting that parts which were in contact have become sepa- rated) implies, in its pathological sense, a collec- tion of pus in any of the tissues or organs of the body. The doctrines of suppuration will be fully discussed in the article Inflammation : in the present we shall consider the subject of internal abscess, including what are termed purulent form- ations. I. Of the various modes tv which puru- lent FORMATIONS TAKE PLACE. The theory of suppuration, or the process by which the secretion of pus from an inflamed sur- face takes place, is, that the purulent fluid is sepa- rated from the blood by a peculiar action of the vessels of the inflamed part, of the precise nature of which we aie ignorant. When purulent matter is confined, and not infiltrated through the structure of an organ, it constitutes, in strict medical language, an abscess, the boundary of which is formed either by the tissue of the organ itself, or by what is called an accidental tissue. In both cases the formation of the boundary is accomplished by the same means, viz. : the effusion of coagulable lymph, which, in the former, produces the union and consolidation of the tissue of the organ in immediate contact with the pus, and thus prevents its diffusion ; in the latter, it forms a more or less perfect mem- brane over the whole of the surface from which the purulent secretion had taken place, and hence, the pus being enclosed, as if in a shut sac, is said to be encysted. It is to collections of purulent matter of the latter kind only, that the term encysted abscess is applied. It would appear that the cysts of abscesses have the property of secreting as well as of ab- sorbing surfaces, from the circumstance of an encysted abscess being often speedily filled after the pus has been evacuated, and that ab.scesses do occasionally disappear without any external open- ing; the only inference in such cases being, that the pus has been absorbed. In most instances, the structure of the tissue ABSCESS, (INTERNAL) 37 surrounding a purulent collection exhibits evident marks of alteration. There is, in general, vas- cular turgescence ; sometimes softening; while, in the part occupied by the abscess, the proper substance of the organ has disappeared, its place being supplied by cellular tissue, in which the pus is deposited. Purulent collections are not always, however, bounded by adhesive inflammation or by a cyst, the pus as it is secreted being in many instances diffused through the tissue of the organ. Such infiltrations of pus happen more frequently in the lungs than in any other organ, and, till lately, were confounded with pulmonary abscess, which very rarely occurs. In most instances the forma- tion of pus which constitutes these infiltrations is preceded by inflammation of the organ in which they are found, but in others it would appear, as we shall presently explain, that the matter is deposited by the blood in healthy structures. Another form of purulent collections is when pus is formed in natural cavities. Serous mem- branes not unfrequently assume a suppurative action as a consequence of inflammation, and in this way large accumulations of puriform fluid take place in the cavity of the thorax, in the abdo- men, and in the interior of the large joints. The fluid effused varies in colour and consis- tence according as it is the product of acute or chronic inflammation. If it is the result of acute inflammation, it is of a pale yellow or straw colour, transparent, or more frequently turbid, from admixture of small portions of coagulable lymph, giving the fluid very much the appearance of unstrained whey ; when it occurs after chronic inflammation, the fluid is not only more abundant, but also more turbid, from the greater quantity of purulent flakes with which it is mixed, and which are often deposited in such abundance as to give the effusion very much the appearance of common pus. These puriform fragments fall to the most depending part of the cavity, so that the upper portion of the fluid is of a thinner consistence than the under or more depending. The portions of the inflamed membrane are covered with an exudation of coagulable lymph, which, when recent, is easily detached ; and when this new formation has become vascular, it is changed into a new structure, to which the term false mem- brane has been given. We have hitherto been considering the forma- tion of pus as the consequence of previous in- flammation of the structure in which it is found. It is necessary, however, to point out, that pus is occasionally deposited in parts which exhibit no traces of the existence of antecedent inflamma- tion. This fact has been long known to patholo- gists. Mr. John Hunter was acquainted with the occurrence of these non-inflammatory purulent deposits, as appears from the chapter in his work on Inflammation, entitled, " Collections of Mat- ter without Inflammation," and since that time the fact has been noticed by various writers both in this and in other countries. Though Mr. Hunter states that there is often swelling, or thickening of parts, without the visi- ble or common symptoms of inflammation, and that there are collections of matter somewhat similar to suppuration which do not arise in con- sequence of common inflammation, he does not appear to favour the doctrine of the possibility of pus being absorbed into the blood, and afterwards deposited in another part of the body ; but to regard all such collections of matter as of a scro- fulous nature, and different from true suppuration. It is also evident that Mr. Hunter had only observ- ed these purulent depositions in external struc- tures. Subsequent observations however have proved that they also take place both in internal organs and in the different cavities, though there be no evidence of inflammation having previously existed. It is the opinion of Andral and other patholo- gists that these purulent deposits are the results of absorption of pus, and that the pus, after it is absorbed from the suppurating cavity, is separated from the blood on the surface or in the interior of the various organs. Andral seems also inclined to think that pus is much more readily formed in some persons than in others; in fact, that there is in some individuals what may be termed a purulent diathesis. These depositions of pus succeed most fre- quently to injuries and surgical operations. They are by no means however confined to these cases; for instance, they are not uncommon after phle- bitis, or in fatal cases of puerperal peritonitis, and in inflammation of the uterus. They also occa- sionally, though rarely, occur after continued fever and erysipelas. There are few tissues in which these non-in- flammatory purulent deposits have not been found. They form in the brain, in the cavity of the thorax and abdomen, in the muscular tissue of the heart, in the parenchyma of the lungs, liver, and spleen, in the substance of the uterus, in the ovaria, in the external cellular membrane, and in the joints. II. Abscess iit particular tissues. Although there is no structure in the human body, if the epidermis, nails, and hair be except- ed, which does not occasionally become inflamed, yet abscess does not form in every tissue ; a par- ticular kind of structure being apparently neces- sary to its formation. For instance, it cannot take place in the dense structure of fibrous or cartilaginous tissue, nor in that of serous mem- branes. When pus is discharged from these tis- sues, it is effused, either upon their surfaces, or into the r/avities which they invest; but abscess never forms in theit proper substance. It would appear that abscess occurs in those organs only into which cellular membrane enters as one of their constituents : of all the structures of the body, cellular membrane is that in which abscess most frequently takes place. It forms more frequently in superficial than in deep-seated cellular tissue; this depends not on the principle that there is a greater inherent disposition in superficial cellular membrane to assume inflam- matory action, but that from its position it is more likely to be exposed to the exciting causes of in- flammation than that which is deep-seated. Pus occasionally forms in muscular structure ; in those cases it is deposited in the intermuscular cellular tissue, the muscular fibre itself being apparently incapable of assuming the suppura- tive action. Purulent matter has been found in all the parenchymatous tissues, either in the form of abscess or of purulent infiltration; as, for in- stance, in the lungs, in the liver, in the spleen, 38 ABSCESS, (INTERNAL) pancreas, and in the kidneys. The encysted abscess is more common in the liver; the puru- lent infiltration in the other organs. With regard to abscess in nervous tissue, Andral remarks, " It is a question which yet re- mains to be decided, whether, when the nervous tissue is in a state of suppuration, the pus is furnished by the nervous tissue itself, or by the cellular membrane which enters into its composi- tion. It is, however, certain, that in some cases of abscess of the brain we find in the seat of suppuration nothing but a congeries of cellular tissue, which, in all probability, is the only source from whence the pus is derived, inasmuch as the nervous tissue has completely disappeared. Cer- tain white softenings of the brain have been re- garded by some authors as the effect of a purulent infiltration of the nervous tissue. This is a mere gratuitous hypothesis; there is no proof whatever of the presence of pus in these cases of soften- ing : all that the most minute examination can detect is a diminution in the consistence of the nervous tissue, which in those cases appears to manifest a disposition to return to its original state." (Vol. i. p. 498, Translation.) In alluding to purulent effusions in the cavities which are lined with serous membranes, we stated that pus is frequently secreted by serous tissue in a state of inflammation. Mucous membranes, however, take on the sup- purative action more easily than the serous. From the extent of this structure in the animal economy, suppurative inflammation of mucous membranes is by no means uncommon. It occurs, for instance, in the bronchial membrane; in the mucous lining of the kidney, bladder, and urethra ; in those shut cavities which are lined with mucous membrane, as in the maxillary and frontal sinuses; in the cavity of the tympanum, and in the ethmoidal cells. There is an import- ant difference in the inflammation of serous and mucous membranes—the former are very liable to adhesive inflammation, which it is hardly possible to excite in mucous membranes. Lastly, pus has been found in the vascular sys- tem, even in the blood itself. It has been detect- ed in the veins which return the blood from parts in which pus has been collected ; and also in in- flamed veins from puncture or after operations. The lymphatic vessels frequently contain pus, as, for instance, when they originate in textures which are in a state of suppuration. III. Of purulent Formation in Organs. 1. Abscess in the Brain.—The brain is not unfrequently the seat of purulent deposits — the pus being, in some cases, infiltrated through its substance ; in others, collected in distinct cavities of different sizes. Sometimes several small ab- scesses unite so as to form a large cavity. Accoiding to Andral, in the primary stage of cerebral abscess, small drops of pus are seen scat- tered, in greater or less numbers, through a por- tion of the nervous substance, which is, at the same time, generally injected and softened. These drops gradually multiply, extend, and run into one another ; the solid parts between them grow softer and softer, and at last appear dissolved, as it were, in the pus, leaving only a few filamentous frag- ments behind. We have, then, a cavity, which however does not become distinctly circumscribed till some time afterwards. When the parietes of this cavity first become distinctly marked, they consist merely of the nervous substance itself; but, subsequently, we observe on their surface, in succession, first, a cellulo-vascular substance, either spread uniformlv over their whole extent, or existing only in small isolated points : secondly, a real membrane, which, however, is still soft, flocculent, and separable from this nervous sub- stance : thirdly, a membrane of more firm con- sistence and distinct organization, which is suffi- ciently tenacious to be detached, either in shreds, or in a single piece, from the subjacent tissue. (Vol. ii. p. 770.) The portion of the brain surrounding the ab- scess is generally softened, when it is recent; but when it has existed for some time, the structure in the immediate vicinity is very liable to become inflamed, and to undergo various morbid altera- tions consequent to inflammatory action. When the abscess is situated near the ventri- cles, the purulent matter may force its way into them, from the slow and progressive destruction of the cerebral substance. When it is nearer the surface, it generally extends outwards, and then bursts between the membranes. In those cases in which the cerebral abscess is situated near the internal ear, the diseased action sometimes extends to the bony structure of this organ, destroying, first, the dura mater, and after- wards the petrous portion of the temporal bone. In this way the contents of an abscess in the brain have been discharged through the ear. In other instances the disease commences in the ear, and spreads to the membranes and substance of the brain. On dissection of such cases pus is found in the internal ear; the dura mater is softened and detached from the inner table of the skull; the brain softened, and either infiltrated with pus, or containing an abscess. Several interesting cases of this kind are recorded in the works of Lalle- mand, Itard, Abercrombie, and others, to which the reader is referred. Cerebral abscess has been known in some in- stances to terminate, also, in destruction of the cribriform plate of the ethmoidal bone; and in this way the matter has been discharged through the nasal fossae. Purulent collections are occasionally found in the cerebellum. It has been remarked as diagnos- tic of these latter cases, that the mental powers are little, if at all, impaired; hence the symptoms of this lesion are very obscure and unsatisfactory. Andral states that in one solitary instance the tu- bercula quadrigemina and pineal gland were found completely destroyed, and their place occupied by an abscess. From the structure of the medulla spinalis be- ing precisely similar to that of the brain, this por- tion of the cerebral organization is liable to the same morbid changes. It has been found, in some instances, infiltrated with pus; but there is no recorded case of abscess in its substance. Dr. Carswell met with a case of abscess of the spinal marrow, in a woman of 45 years of age, a patient of Mons. Louis, and the particulars of which were furnished him by Mons. Reynaud. The pus oc- cupied the cortical substance of the right anterior half of the spinal marrow, formed a cylindroid abscess nearly rive inches in length, and, in some parts, more than a line in diameter. A similar collection existed in the left anterior half, and was ABSCESS, (INTERNAL) likewise limited to the situation of the cortical substance ; but it was not more than an inch in length, and terminated in the former, about an inch and a half above the primary seat of the in- flammation. With regard to the progress of cases of cerebral abscess, it would appear, from the symptoms ex- hibited previous to the deposition of pus, that in- flammation of the membranes or substance of the brain always precedes the formation of matter; that after the deposition of pus the inflammatory action ceases, the symptoms diminish, and the functions of the brain are in part or entirely re- stored, notwithstanding the presence of such a foreign body as an abscess. The disease may then lie dormant for a considerable time, till the portion of the brain immediately in contact with the ab- scess takes on inflammatory action, and then the features of the malady again indicate inflamma- tion of the brain, of a more or less acute charac- ter, which generally proves fatal; death being caused, not by the abscess, but by the inflamma- tion which supervenes. It must be admitted that, in investigating the history of several recorded cases of abscess of the brain, we find the train of symptoms very obscure and unsatisfactory. 2. Abscess in the interior of the Month and Pharynx.—The tongue is liable to inflam- mation and its consequences. Abscess in its sub- stance, however, is a very rare occurrence. Though Andral alludes to it after acute inflammation, we have not been able to find an instance on record. Abscess frequently succeeds to inflammation of the tonsils and pharynx. The cellular tissue which surrounds the amygdalae is very liable to inflammation, which occasionally terminates in suppuration, the matter being discharged into the mouth. When the abscess is large, there is great danger of suffocation from the pressure of the swelling on the glottis. Such abscesses some- times form in the progress of acute diseases, more particularly fever, and the acute eruptive disorders of children, and give rise to all the symptoms of croup. If the tumour can be discovered, it should be opened by puncture ; indeed, in some instances of this kind, promptitude is necessary to save the patient's life. When an abscess occurs in the pharynx, it is apt to be overlooked, because, from its situation, it cannot be easily seen. When it is suspected, the finger should be carried down the pharynx, and, if necessary, the tumour opened, as death has occasionally occurred from its pressure on the glottis. This has occasionally happened in fever and acute eruptive diseases. Abscess in the cellular tissue connecting the mucous membrane with the muscular tissue of the oesophagus occasionally takes place, and gives rise to dysphagia, more or less urgent according to the extent of the purulent formation. When such abscesses attain a large size, they not only impede deglutition, but, by pressing on the trachea or lungs, produce considerable cough and difficulty of breathing. It is often very difficult to distinguish abscess from stricture of the oesophagus. In some in- stances, on the introduction of the probang, in order to ascertain the cause of dysphagia, the true nature of the disease has been ascertained by the rupture of an abscess, and the discharge of pus from the oesophagus. Adhesive inflammation sometimes takes place between abscess of the oesophagus and the adjoin- ing structures. In this way an abscess of the oesophagus, by adhering to the lung, has been dis- charged through the bronchial tubes. 3. Purulent Formations in the Chest.— 1. Purulent effusion into the cavity of the chest is not unfrequently the termination of pleurisy, particularly of the chronic form, and constitutes the disease termed empyema, which it is evident can only be considered as a secondary affection. The character of the fluid effused into the sac of the pleura differs according as it arises from acute or chronic pleurisy. When it succeeds to the former, it is of a pale yellow' or straw colour, and generally a little turbid from being mixed with the coagulable lymph which is secreted by the in- flamed pleura. In chronic pleurisy, the fluid is not only in larger quantity, but of a consistence approaching to that of common pus, and generally mixed with masses of coagulable lymph. As pleurisy seldom takes place in both sides of the chest at the same time, effusion is generally observed in one cavity only. The fluid is some- times very rapidly secreted ; in other instances it takes place slowly and insidiously, the lung on the diseased side being compressed and pushed to- wards the upper part of the chest, in which situa- tion it is often retained by adhesions. The lung is sometimes so reduced in size as to be scarcely more than four to six lines thick, even in its mid- dle, and without careful examination might be considered to be totally destroyed. Sometimes a tubercle in the stage of softening, when situated near the pleural lining of the lung, bursts into the cavity of the chest. Pneumotho- rax immediately follows ; this is succeeded by in- flammation of the pleura, and rapid effusion, which proves fatal in a very short time. In some cases, however, adhesive inflammation takes place between the pleura pulmonalis covering the tuber- cle and the walls of the thorax ; and thus the con- tents of the tubercular cavity are prevented from escaping into the sac of the pleura. In other in- stances, the adhesive inflammation extends to the parietes of the thorax, and in this way tubercular matter escapes through a perforation in the chest. (See Pneumo-Thohax and Tubercle.) Abscess of the liver or spleen occasionally bursts into the cavity of the pleura, and induces inflam- mation of the pleura and purulent effusion. 2. Abscess of the lung is a lesion very rarely met with, though from the frequent mention made of this pathological phenomenon by British as well as by some continental writers, we should be led to imagine it was a common termination of pulmonary inflammation. The opinion of Laen- nec on this point is very strongly expressed. It appears from his statement, that there is no organic lesion more rare than a collection of pus in the substance of the lung; and that, among several hundred dissections of persons who died of peri- pneumony, he had only met with a collection of pus in five or six instances, and in these purulent deposits were neither extensive nor numerous in the same lung. In three cases only was the col- lection of pus of considerable extent, but in these there was no circumscribed cyst, the wall being formed by the pulmonary tissue, which was much softened and disorganized. Laennec also states | that he had been able to find only two similar 40 ABSCESS, (INILRNaL) cases on record, neither of which had the proper cyst of phlegmonous abscess. Andral mentions the case of a new-born infant, whose lung contained several large abscesses. They had no resemblance whatever to tubercular excavation. (Vol. ii. p. 539, Translation.) 3. The kind of suppuration to which the sub- stance of the lung is occasionally liable is purulent infiltration. When it occurs, it is accompanied with hepatization, and appears to succeed to the most intense degree of inflammation. The con- sistence of the lung is at the same time much diminished, being so soft as to break down when handled. The pus appears in small detached points, so that when the lung is incised or squeezed, opaque yellow matter flows out. It may occupy an entire lobe, or only a small portion of it, and sometimes succeeds to pneumonia with great rapidity. Andral asserts that it has been found fully formed four days after the first symp- toms of pneumonia had made their appearance. The pulmonary parenchyma when infiltrated with pus presents a greyish ash colour, and, as the second stage of pneumonia has received the name of red hepatization, the former condition has been distinguished by the term grey hepatization. When the lung, in this state, is pressed, the puru- lent fluid exudes in greater or less quantity, and when it is squeezed out, the lung frequently re- assumes the red colour and hepatized appearance of the second stage; thus proving, as Andral states, that the grey hepatization differs only from the red in having its structure infiltrated with pus. 4. The process of softening of tubercles presents another variety of purulent formation in the sub- stance of the lung. These bodies, which vary in size, are in their first stage semi-transparent, and of a greyish colour; in some cases almost colour- less and transparent. In this state they are pro- ductive of little inconvenience ; and hence indi- viduals, with pulmonary tubercles, often enjoy uninterrupted health for years. Sometimes a single tubercle has been found, but more generally they are numerous, and situated in the upper part of the lung. In some cases they are superficial, in. others deep-seated. The tendency of these bodies is to soften, and to form a cavity in the portion of the lung where they are situated. The softening generally commences in the centre, and gradually increases towards the circumference, until the whole tubercle is converted into a fluid mass. One or more of the bronchial tubes become perforated, through which the tubercular matter is evacuated. A tubercular cavity is thus left, the interior of which is traversed by bands of pulmo- nary tissue, covered by tubercular matter, and the smaller branches of blood-vessels, which are gene- rally obliterated and transformed into impermeable cords. In some instances, however, these vessels continue open, and, by their erosion or rupture, occasion haemoptysis. The larger blood-vessels are pressed towards the side of the excavation, lining, as it were, its internal surface. The bron- chial ramifications undergo similar pressure ; but, according to Laennec, they appear to be rather enveloped than pressed aside by the tubercular matter, the pressure apparently soon obliterating their canal, as they are scarcely ever to be detected in the morbid structure of the lung. He moreover thinks they must have originally traversed the portion of lung occupied by the tubercles, as, in even the smallest excavation, one or more bron- chial tubes are found opening into it. These tubes appear not to open sideways, but are cut directly across on a line with the internal surface of the excavation, while from their direction, it is evident that they originally crossed the excava- tion. The boundary of these tubercular cavities is formed by the parenchymatous tissue of the lung, which has become more or less indurated or infiltrated with tubercular matter. The internal surface is lined by a false membrane, which is composed of concrete pus, and is so soft as to be easily detached by the scalpel. These cavities vary in number and size ; some- times there is only one cavity, in others there are several, which either remain isolated, or commu- nicate together by fistulous openings, varying in extent from such as will scarcely contain a filbert, to those which occupy a considerable portion of one lung. With regard to the possibility of the cicatriza- tion, or healing of tubercular excavations, it would appear, from the minute and distinct researches of Laennec, that this process does take place, though in a very small proportion of cases. For a minute account of the stages of this reparative process, we beg to refer to the work of Laennec, and to the article Tubercle. 5. Besides the sero-purulent effusion into the pericardium (from pericarditis,) abscess has been found in the muscular structure of the heart itself. The abscess is not encysted, the pus being dif- fused in the cellular tissue, connecting its muscu- lar fibres ; and in all the instances recorded, it appears that the previous inflammation had been confined to the portion of the structure of this organ in which the abscess occurred. The sub- stance around the abscess is stated, in some cases, to have been natural; in others, it appeared red and softened. Abscess of the heart, however, is a lesion very rarely met with, although frequent allusion to such cases is made by the older writers, who, no doubt, mistook the sero-purulent effusion into the peri- cardium for abscess. There are, however, on record several well-authenticated instances of true cardiac abscess. Laennec mentions the case of a man, sixty years of age, in whom he found an albuminous exudation of the consistence of boiled white of egg, and of the colour of pus, deposited among the muscular fibres of the left ventricle. The symp- toms before death (orthopnoea and indescribable anguish) indicated acute inflammation of some of the thoracic viscera. He alludes to another case, in a child twelve years of age, in whom he found an abscess of the size of a filbert in the left ven- tricle. This case was complicated with pericar- ditis. A similar instance is mentioned by Andral; (vol. ii. p. 345.) In a fatal case of phlebitis after venesection, which occurred at Bethlehem Hospital, Mr. Law- rence found, in addition to the disease of the bra- chial veins, pericarditis, with deposition of pus in the muscular substance of the left ventricle, which was also softened and partially broken down. (Med. Chir. Trans., vol. xv., p. 124.) 4. Purulent Formations in the Abdomen. —1. In treating of the different modes in which purulent matter is deposited in natural cavities we alluded to the suppurative uiflammation of ABSCESS, (INTERNAL) 41 serous membranes. We have already observed that the secretion of puriform fluid is not an infre- quent termination of chronic pleutisy. The same thing happens in peritonitis, in fatal casps of which more or less sero-purulent effusion is found in the abdominal cavity. The consistence and quality of this fluid vary according to the duration of the disease ; and hence, from the character of the effusion alone, its duration may, inmost instances, be inferred. In some instances, circumscribed cavities, containing puriform fluid, are found. These originate in cases of partial or circumscribed peritonitis, the boundary of the cavity being formed by the effusion of coagulable lymph, by which the convolutions of the intestines become agglutinated. In other cases, purulent effusion into the abdo- men has been the consequence of the bursting of an abscess in some of the abdominal viscera__ the liver, for instance—or of intestinal perforation. These intestinal perforations may occur in any portion of the alimentary canal, but most fre- quently take place in the small intestines, and are generally the consequence of follicular ulceration and progressive destruction of the muscular and peritoneal tunics. When the peritoneal coat gives way, the intestinal contents escape into the cavity of the belly, and rapid inflammation, followed by death, is the almost invariable result. In some cases, the adhesion of the bowel to some adjacent part has prevented the intestinal perforation. In a remarkable case of this kind, the abscess communicated with the caput coli, to which, and to the parietes of the abdomen, the omentum had contracted a very firm adhesion. In this manner a circumscribed cavity was formed, bounded by this portion of omentum, the posterior surface of the caput coli, and the portion of peri- toneum lining the parietes at the part. This cavity contained a small quantity of ill-conditioned pus, and three or four bodies which appeared to be the seeds of fruit covered by earthy incrustation. It communicated with the caput coli by a small irregular opening, the mucous membrane around which was thickened and vascular. (Abercrombie, p. 338.) 2. Abscess of the liver is not very common in temperate countries, but is a very frequent termi- nation of hepatitis in warm climates. The pus may be either infiltrated through the substance of the liver, or may be contained in a cyst, forming the encysted hepatic abscess. Abscesses of this organ vary in extent, being sometimes very small, in other cases of a large size, not less than three to four pounds of purulent matter having been found in a single abscess. (Abercrombie.) They differ, also, in number: there may be one abscess only, or there may be several, which are either perfectly distinct from each other, or communicate by fistulous openings. Hepatic abscess, when of small extent, may be absorbed ; more generally, however, adhesive in- flammation takes place between the walls of the abscess and some of the surrounding structures. In this way the pus may be evacuated externally through the parietes of the abdomen ; into the right pleural cavity ; through the diaphragm ; or, should adhesion have taken place between the liver, diaphragm, and parenchyma of the lungs, i the contents of the abscess may be coughed up through an opening in the bronchi, and the patient may eventually recover. In other instances, the j Vol 1—6 » * abscess forms adhesion to some contiguous portion of the alimentary canal, into which the pus is evacuated and discharged, either by vomiting, should the abscess adhere to the stomach, or by stool, if the adhesion takes place to the alimentary | canal. In a case related by Malpighi, in which ■ the abscess was situated near the gall-bladder, adhesion took place, and the contents were dis- I charged through the biliary duct into the bowels. Andral alludes to a case in which an abscess of the liver communicated with the interior of the vena cava, and to another in which it opened into j the pericardium. (Vol. ii. p. 598.) 3. The termination of inflammation of the spleen in abscess is uncommon ; indeed, idiopathic inflammation of this organ is a very rare disease. Purulent infiltration in the spleen, however, often takes place at the same time that pus is deposited in other parenchymatous structures. In these cases, it is probable that the pus is formed else- where, and only deposited in the spleen through the medium of the circulation. Andral mentions the case of a woman, in whom, on dissection, he found a number of small abscesses in the spleen, lungs, liver, and brain ; the uterus, however, was the organ in which the pus was originally formed ; for the symptoms of inflamma- tion of the uterus were those which appeared first; and in the substance of this organ there were several collections of purulent matter, while all the uterine veins were filled with pus. The pus, in abscess of the spleen, may be dif- fused through the parenchyma of the organ, or it may be confined in a cyst of variable extent. The structure surrounding the abscess is sometimes unchanged ; more generally, however, it is softened j and considerably altered in its texture, so as to be pulpy and easily broken down. These abscesses often attain an extraordinary size. In a case recorded in the Memoirs of the Academy of ! Sciences, an abscess of the spleen contained thirty i pounds of purulent matter. In another mention- ed in the same work, eight pounds of matter were drawn off by tapping. The patient died next day, and the spleen was found still to contain seven pounds of pus, the sac of the abscess being eigh- teen inches in length and twelve in diameter. Like abscesses of the liver, those of the spleen, by forming adhesion to some adjoining viscus, may burst into the cavity of the pleura, (Tweedie, Clinical Illustrations of Fever,) stomach, (Coze, Journ. de Med. torn. 82,) colon, (Jacquinelle, Journ. de Med. torn. 88) ; or, by the cyst of the abscess forming adhesion to the kidney, the pus may be discharged with the urine. The matter may be, also, extravasated into the cavity of the belly, in which case it proves rapidly fatal; or the abscess may form an external tumour in the left hypochondrium, and in this way the matter may be discharged externally, by an opening in the abdominal parietes. Among the lesions observed in the spleen in fatal cases of fever, abscess may be enumerated. Though rather uncommon, cases of this kind have been recorded. Mr. Wardrop states, in a note to Baillie's Morbid Anatomy, that in some of the British soldiers who suffered from the Wal- cheren fever, and who afterwards died in this country, the whole substance of the spleen was converted into a puriform fluid, contained in its proper capsule. 42 ABSTINENCE. 4. The pancreas is very rarely diseased, altera- tions of structure being less frequently observed in this than in any other organ of the body. Sev- eral cases of pancreatic abscess, however, have been recorded. Baillie mentions one case of-it: the abscess contained a considerable quantity of thin pus; the pancreas being much enlarged in size. Portal mentions having met with several instances ; and Andral once found two abscesses imbedded in the structure of the pancreas, each of which might have held a hazel nut. In a case mentioned by Dr. Percival, in which there was jaundice with bilious vomiting, epigastric tumour with discharges of blood and fetid pus by stool, the pancreas was found greatly enlarged, and con- tained a large abscess, the ductus communis being obliterated by pressure. 5. The intestinal absorbents occasionally sup- purate, the pus being either collected in a cyst, (the parenchyma of the gland being destroyed,) or diffused through their structure. In scrofulous children, in whom mesenteric disease is more fre- quently met with than in adults, these glands are enlarged, and when cut into are found to contain soft curdy matter intermixed with pus. 6. Abscess is a common termination of inflam- mation of the kidney. Renal abscesses are gene- rally small; they are sometimes, however, of con- siderable size, and lined with a soft membranous layer. Purulent infiltration of the kidney has also been observed, co-existing with purulent col- lections in other organs. The abscess, again, may be exterior to the kidney, in the cellular tissue in which this organ is imbedded. The pus formed in renal abscess in general passes through the ure- ters into the bladder, and is then expelled with the urine. Adhesive inflammation may, however, take place between the wall of the abscess and the parietes of the abdomen, and a communication has thus been formed between nephritic abscess and the loins. In some rare instances the abscess has burst into the colon, and the contents have been discharged by stool. A case of this kind is mentioned by Lassus. It should be remembered, however, that when puriform matter is passed with the urine, it is not always from abscess of the kidney. The mucous membrane lining the pelvis and ureters, or the bladder, occasionally becomes inflamed, and after- wards assumes, like other mucous membranes, a suppurative action. It is impossible during life to distinguish the one class of cases from the other ; nor is this of much practical importance, since the treatment is precisely the same in both. 7. Abscess occasionally forms in the muscular structure of the uterus, either in a circumscribed cyst, or infiltrated through its substance. In these cases, the uterine and hypogastric veins often con- tain pus, and it is by no means uncommon, as has been already stated, to find purulent deposits, at the same time, in other organs. When pus is found in the uterine veins, the prevailing opinion among pathologists is, that it is the result of ute- rine phlebitis, and that the pus which is found in other organs is deposited by the blood in its pass- age from the uterus through the various parts of the sygtem. Pus may also be collected in the cavity of the uterus and Fallopian tubes. Dr. Carswell met with one case in which the pus col- lected in the cavity of the uterus was prevented from escaping by the presence of a false mem- brane, which passed across the orifice of the neck of the uterus. 8. Though abscess be an occasional termina- tion of ovarial inflammation, it is by no means common. There are several examples, however, on record, of ovarial abscess which varied much in size. In a case which lately occurred to the writer of this article, (the prominent symptoms of which were uncontrollable vomiting and sym- pathetic fever,) the ovarial abscess was of the size of an orange. They sometimes attain an enor- mous size ; as in a case related in the North Ame- rican Medical and Surgical Journal for 1826. A woman had an abdominal tumour which was ima- gined to be ovarial dropsy. Its real nature was only discovered after death, when the tumour was found to be a sac, containing twenty pints of well- formed pus. In some cases, the capsule of ovarial abscess has burst, and the pus has been extravasated into the cavity of the belly. An interesting case of this kind is related by Dr. Seymour, in his work on Diseases of the Ovaria. In this case, the young woman, after suffering some time from hectic fever, (the cause of which was not very apparent,) suddenly complained of most acute pain over the abdomen, and in a few hours expired. On opening the body, the cause of death was ap- parent. A large quantity of pus was effused into the peritoneal cavity, which had escaped from an abscess in the right ovary. The ovarial abscess sometimes adheres to an adjacent organ, either to the uterus, vagina, blad- der, or to some portion of intestine. In these cases, the pus is discharged eventually into the J viscus to which the abscess adheres. Lassus mentions the case of a woman who had long suffered from pain in the right lumbar region, supposed to proceed from suppuration of the kid- ney, because pus was voided with the urine. Af- ter death, the right kidney was found in its natu- ral state, but there was an abscess in the right ova- rium, which was adherent to the bladder, into which the pus had passed through an ulcerated communication. Andral met with a similar com- munication between one of the ovaries and the bladder in a young woman, who died thirty-seven days after her confinement . m A. Tweedie. /ABSTINENCE. By this term is meant the excessive or total privation of food. The animal frame is described by M. Cuvier as a tourbillon, by which substances are continually taken from without, carried into the circulation, deposited, re-absorbed, and finally rejected. The mass both of the fluids and of the solids is thus supplied, repaired, or renewed. If our object be to diminish this mass, abstinence affords us, not the most prompt, but the most permanent and natural remedy. Not the mass only, but the sentient and moving powers of the system are diminished bv the pri- vation of food ; and this both in regard to ani- ' mal and organic life, to use the useful and expres- I sive terms of Bichat: so that if our further object be to reduce the powers of the system, abstinence I still furnishes us with the most simple and direct j remedy. The ancient physicians were so impressed with the importance of various modifications of diet in | the treatment of diseases, that they divided the ABSTINENCE. 43 whole art of physic into dietetics, pharmaceutics, and surgery. (See Celsus, pratf) And, in re- gard to the employment of abstinence, the rules of Hippocrates for the treatment of a patient af- fected with varix or aneurism are precisely the same as those of Valsalva ; that is, dieta qua quam siccisimus et exsanguissimus fiat. (De Morbis, lib. i. sec. x.) Man is thus sometimes subjected to the effects of abstinence by the prescription of the physician. Those effects are sometimes carried to the last extremity by accident or calamity ; sometimes by obstruction in the oesophagus ; and sometimes by the phrensy or monomania of the patient. In these several cases, we have, therefore, the oppor- tunity presented to us of observing the effects of the privation of food on the human subject. The investigation has been made still more complete, by experiments upon the lower animals. (See Recherches sur la Digestion, par Tiedemann et Gmelin, pp. 91, 160.) In order that we may give as practical and useful a view of this subject as possible, we shall treat of it under three heads : —1. Of the curative effects. 2. Of the morbid effects of abstinence employed as a remedy. 3. Of the morbid effects of famine in the other cases to which we have alluded ; and, lastly, of the pro- per mode of treatment. Curative Effects of Abstinence. — Ri- gid abstinence is a most powerful remedy in all acute dieases. It should, in such cases, be car- ried far beyond the degree prescribed as a part of the antiphlogistic regimen; the object being not so much to avoid stimulus, as to in- duce actual lowness, to subdue the powers of the system. Abstinence is also a valuable remedy in many of the more chronic forms of disease : a state of extreme inanition of the stomach not only enfee- bles the circulation, but acts most powerfully upon the absorbent system. With this view it has been proposed to institute a system of rigid abstinence in cancer : it might probably be more successful in some kinds of dropsy. An obvious application of abstinence, as a rem- edy, is that made in cases of disorder or disease of the stomach itself. These affections are so con- stantly the effects of improper food, that, to change the diet is obviously but to remove the most usual cause. To withdraw food nearly altogether for a time would, doubtless, be to employ an actual and powerful remedy. This is so evident, and yet the facts in illustration are so few in number, that we cannot but recommend the subject for fu- ture inquiry. If a joint be morbidly affected, we enjoin the most absolute repose. The value of a well-regulated but rigorous abstinence in cases of disorder or disease of the stomach itself, and of some of the chylopoietic viscera, especially the liver, would, doubtless, be equally great. This subject has been well touched upon by Dr. J. John- son ; and the writer of this article can add his testimony to the beneficial effects of abstinence in the cure of these diseases. It is impossible to refer to the subject of the use of abstinence as a remedy in disorders or diseases of the stomach, without recalling to our minds the services which M. Broussais has rendered to this department of medicine : the diife absolute, or extreme abstinence, reeommendeJ in gastritis by that author, is, assuredly, a far more natural and appropriate remedy, than the mistaken adminis- tration of drastic purges, too much employed in this country. The next object in enjoining abstinence, is to reduce the mass of solids and of fluids. Absti- nence is, therefore, the most direct remedy for plethora. This point has been ably treated of by Dr. Barlow, of Bath, in his Treatise on the Bath Waters. See the article Antiphlogistic Regi- men. The case which next presses itself upon our notice, in regard to abstinence as a remedy, is that of disease, or tendency to disease, within the head. The immediate threatening of apoplexy must be treated by active blood-letting; but the remedy for the permanent disposition to this dis- ease is the most strict abstinence. The most rigorous system of weighed or measured portions of the least nutritious and least stimulant kinds of food is to be enforced. We must now add a few words upon the cele- brated use of abstinence in diseases of the heart and arteries, in the hands of Valsalva, as described by Morgagni, (lib. ii. ep. xvii. § 30,) from the account given to him by Stancarius. Sufficient blood having been taken, Valsalva ordered the food and drink to be daily diminished, until it was reduced to half a pint of gruel in the morning, and less than half that quantity in the evening ; to this water alone was added, and that in a cer- tain measure only, medicated by the addition of quince, &c. When the patient was, in this man- ner, emaciated, and so debilitated that he could not raise his hand from the bed, the diet was slowly and moderately increased, so as just to maintain power enough for raising the body. In this manner these formidable diseases were cured. It is confessed, (§ 31,) that some thought the cure of Valsalva worse than their aneurism. But it was argued that that which was not done early in the disease, with the hope of cure, might be- come necessary during its progress, without such hope, from the incapacity for swallowing. Having thus noticed the principal applications of abstinence in the cure of disease, we pass on to describe its morbid effects when inappropriately or improperly applied. 2. Morbid effects of abstinence. — The morbid effects of abstinence usually steal on the patient, and even the physician, imperceptibly. The excessive privation of food is unnatural, and therefore not to be borne long with impunity. If M. Broussais has, as we have stated, done much good, he has, also, been the author of much mis- chief. He has passed from extreme to extreme, and, in removing irritation, he has frequently in- duced a state of exhaustion not less painful and perilous. Interesting accounts of such events have been published by M. Barras and M. Cafort. (See the Med. Chir. Rev. for Jan. 1, 1831.) Still more recently the subject has been treated, at considerable length, by M. Piorry. (Proced6 Opiratoire, &c, Paris, 1830, p. 368.) Having referred such of our readers as may desire to enter more fully into the subject for themselves, to these latest sources of information, we purpose to subjoin our own remarks. We think, in the first place, that the effects of extreme abstinence and its concomitant exhaustion have, generally speaking, not been understood; and, in the second, that the morbid effects of abstinence 44 ABSTINENCE. have, more frequently than is supposed, arisen from its misapplication. The first part of the series of the effects of abstinence consists in simple debility and emacia- tion. The countenance becomes pale, and the expression languid; the muscles of voluntary motion become thinner and feebler; the pulse feebler and smaller. The second part of the series is different. The pulse is augmented in frequency; there is often palpitation of the heart, alternately with syncope ; and there is pain of the head, or delirium ; symptoms which might be mistaken, by the inexperienced or unwary, for those of increased action and power, whereas they are but the feeble flashes or glimmerings of a light ready to become extinct. Such a transition in the effects of abstinence is frequently the consequence of an undue ad- ministration of this remedy ; still more frequently, however, it arises from its inappropriate applica- tion. When cases of irritation are mistaken for those of inflammation, the morbid effects of ab- stinence are particularly apt to occur. The for- mer disease neither requires nor bears the remedy; whilst, in inflammation, it is both essential to the cure of the disease and well sustained by the patient. This is a point which requires fo be well investigated. The ancients, and especially Celsus, speak of a principle of encouragement in the sick which they expressed in these words — difficulter ferre morbum, (lib. iii. § 3.) There is another principle not less important, — diffi- culter ferre remebia. It would be difficult to induce the morbid effects of abstinence when there is a tendency to apoplexy ; but it would be very easy to do so if palpitation, or some other symp- tom of gastric irritation, were mistaken for dis- ease of the heart, or for inflammation. 3. Effects of famine.—In order that our detail of the morbid effects of abstinence may be the more complete, we subjoin a more detailed account of the series of phenomena in those cases which have been continued to extremes. The first case in point we extract from the recent excellent work of M. Andral. (Pricis cTAnatomie Pathologique, torn. ii. p. 769.) A man, addicted to drunkenness, was cast into pri- son *for theft, and reduced, at once, to a diet of bread and water. After the first week, a disorder of the intellectual faculties took-place; his coun- tenance became pale and expressive of languor, his flesh wasted, and his strength declined ; his nights were sleepless; shortly afterwards there was delirium, which was mild at first, but subse- quently furious. The prisoner was now allowed brandy. The cerebral symptoms disappeared, and the flesh and strength returned. The effects of abstinence and of an amelioration in the diet are so obvious in this brief case that it is full of in- struction. Abstinence and excess induce similar symptoms and effects; a fact which cannot be too deeply impressed upon the mind of the young practitioner. Dr. P. M. Latham's interesting account of the epidemic at the MiUbank Penitentiary is full of facts which bear upon the same point. We refer our readers to it for much information. The late Dr. Gooch observes, in regard to this epidemic, that " the prisoners were suddenly put opon a diet fiom which animal food was almost entirely excluded. An ox's head, which weighs eight pounds, was made into soup for one hundred peo- ple, which allows one ounce and a quarter of meat to each person. After they had been living on this food for some time they lost their colour, flesh, and strength, and could not do so much work as formerly." "At length this simple debility of constitution was succeeded by various forms of disease : —they had scurvy, dysentery, diarrhoea, low fever, and, lastly, affections of the brain and nervous system." The affections, "which came on during this faded, wasted, weakened state of body, were head-ach, vertigo, delirium, convulsions, apoplexy, and even mania. When bleeding was tried, the patients fainted after losing five, four, or even fewer ounces of blood." On examination after death, "there was found increased vascularity of the brain, and sometimes fluid between its membranes and in its ventricles." (Account of Diseases peculiar to Women, p. 150.) Interesting cases of abstinence are recorded, with the full detail of its symptoms, by Dr. Currie, (Medical Reports, Ed. 4, vol. i. p. 304,) and by Dr. Willan, (Miscellaneous Works, by Dr. Ashby Smith, p. 437.) To these cases we refer our readers; extracting only what will be sufficient to portray the usual character of the late symp- toms in the case of inanition, and lead to the due distinction between the symptoms of disease of the nervous system, which arise from it, and those which depend upon a primary disease of the brain itself; for the case of extreme abstinence or famine affords a remarkable instance of the singular effects of exhaustion, and their similarity to those of diseases of a totally opposite nature and origin. Dr. Currie describes the effects of inanition in a case of obstructed oesophagus, as involving the following circumstances : — The patient's age was 68. The obstruction in swallowing gradually increased from the begin- ning of August, and on the 1st of November it was complete. The following plan was adopted: each morning, at eight o'clock, he had a clyster consisting of eight ounces of broth, two yolks of egg, and forty drops of laudanum ; this was re- peated at three p. m., and at nine p. m., with thrice the quantity of laudanum. Previously to the evening draught, a bath was used, consisting of one-fourth part of milk, and three-fourths of water, at 96°. In a few days the clysters were augmented in quantity, and eight ounces of wine were added, with an increased dose of laudanum. This plan was continued until the second of December. The. rectum then ceased to retain the clysters, and their employment was relinquish- ed. In spite of these plans the emaciation was rapid : the patient had weighed 240 lbs. when in health ; on the 20th of November, he weighed 154 lbs.; and on the 25th, 149 lbs. only. The pulse, during the month of November, was that of health ; on the first of December, it became small and frequent; on the second, it was still more frequent though stronger, with delirium, and the case resembled the last stage of fever. " During this delirium, a perpetual and indistinct muttering occurred, with great restlessness and agitation ; the surface and extremities were some- times of a burning heat, sometimes clammy and cold. The eyes lost their common direction, the axis of each being turned towards the nose. In this state, however, the sensibility of the retina ABSTINENCE — ACHOR. 45 w*s not impaired, but rather increased, for he creamed out on the light of the window being admitted, to which before he had been accustom- ed. At this time also the sense of touch seemed more than usually acute, for he appeared disturb- ed with every accidental breath of air. The deli- rium and the derangement of vision commenced nearly together, but we observed the derangement of vision first. On the first of December he com- plained that he sometimes saw double ; but it was not till the succeeding day that any considerable incoherence of mind was observed. The pulse became feeble and irregular on the fourth; the respiration, which had been singularly undisturb- ed, became laborious ; the extremities grew cold ; and in jiinety-six hours, after all means of nutri- tion as well as all medicine had been abandoned, he censed to breathe." During the first periods of tbis case there was little complaint of hunger or tiirst; there was a stool, of a solid form, pale colour, but natural foetor, with each fifth glyster. The spirits were even, and the nights good. Dr. Willan's case was one of monomania. He visited the patient on the 23d of March, 1786, on tbe sixty-first day of his fast. His emaciation was extreme, and he laboured under great imbe- cility of mind; the eyes were not, however, defi- cient in lustre, and the voice remained clear and Bound. He was directed to drink a pint of barley water, and two cups of panada, which agreed. He had a little fever in the first part of the night, but slept better than usual. On the 24th he had some mutton-tea; the pulse was small and tem- perate. On the 25th he took a pint of milk for breakfast; a pint of mutton-broth boiled with barley for dinner, and as much rice-milk for sup- per, at his own request. He had considerable cravings for food all the day. In the morning of the 26th he drank tea, and ate a great quantity of bread and butter, which he got from off the table in the nurse's absence. Some time after he became sick, and vomited once or twice without much straining. About noon he had a figured natural stool, and presently after two or three loose motions. His skin was always dry. In the evening he was apparently much better ,- the pulse ninety and firmer. On the 27th he took a little light bread pudding at dinner, and had two eggs for supper ; he rested well and was cheerful. On the 28th he seemed better; he had not slept well, however, nor had a stool. On the 29th the scene was entirely changed ; he began to lose his recollection in the preceding evening ; and before midnight became quite frantic and unmanageable. His pulse, was increased in frequency, with con- siderable heat on the skin, and tremors. He con- tinued raving, and talking very incoherently, as he had done during the night. A strong purga- tive draught, and two clysters administered in the course of the day, produced but little evacuation. He remained nearly in the same state of mind as above-mentioned, scarcely ever sleeping, and taking very little nourishment, till the 2d of April, when a considerable quantity of loose feculent matter was brought away by a clyster. Soon after he became sullen, and took no notice of what passed about him. He was removed at this time into the country, so that he was not seen again till the 6th of April. He appeared then emaciated to a greater degree, if possible, than at he first. His pulse was small and feeble, beating 120 strokes in a minute. April 7th and 8th he took whatever nourishment was offered him; knew those around him, and spoke sensibly, but faintly. On the 9th, in the morning, he died, quite exhausted. The case of abstinence affords a beautiful illus- tration of the fact, that cerebral symptoms, resem- bling those of increased action, do also arise from the opposite state of the brain and of the system. The effects of exhaustion frequently stimulate phrenitis in adult age, and hydrocephalus in in- fancy, and it requires the utmost attention and sagacity to distinguish them. 4. Mode of Treatment.—The treatment of the morbid effects of abstinence, like the treatment of the effects of exposure to severe cold, consists principally in the cautious re-administration of the natural stimulus. All solid food must be avoided at first, and especially milk, which becomes solid in the stomach, and is more difficult of digestion than other solids from being unmasticated. A little thickened broth should be given at intervals of four hours, and the quantity very grad ually increased; and the bowels should be carefully relieved by enemata of barley-water. No one can read the case of Dr. Willan without being impressed with the conviction that the treatment was most injudicious. To allow three pints of food,— milk, broth, and rice-milk, on the third day, after an abstinence of sixty days, was quite preposterous. One-third of this ration would have been far too much ! There is another aspect in which the effects of abstinence and their treatment may be viewed. Mr. Hunter observed, (Animal Economy, pp. 114, 115,) that if an animal be enfeebled by abstinence, its power of maintaining its temperature is also lessened. It occurred to the writer of this article to witness the same fact: some white mice had been neglected, and passed upwards of forty hours without food ; they had become torpid and cold ; by being held in a warm hand they were perfectly restored to life and activity before a morsel of food had been administered. From these facts we may deduce the inference, that to administer warmth is one of the most efficacious modes of remedying the effects of abstinence. % A third remedy is also very important. It consists in assiduous frictions. In cases of absti- nence the powers of the circulation are greatly enfeebled. The most direct mode of restoring these powers, after the administration of food and warmth, is friction in the course of the venous blood. This remedy, therefore, must not be neg- ,ected- Marshall Hall. ACHOR, like most of the terms used to denote the morbid appearances presented by the skin, had no definite meaning before the time of Willan. By the word d^wptj, Galen and the ancient writers who followed him understood " ulcerations pecu- liar to the hairy scalp, discharging, from very small pores, a viscid ichor, consequent to pustules." They were considered by them as a smaller spe- cies xripiov, or favus, from which the latter only differed in exhibiting larger perforations, and in discharging humour similar in colour and consis- tence to Hymettian honey. Alexander Trallianus and Actuarius first distinguished the pustules from the ulcerations in which they terminate. The Arabians, simply translating Galen, described 46 ACNE. the achores and favi under the titles of alsahapha, or alsahaphati, and alsahara. By the early modern writers, achores — manantia ulcera capitis—were confounded with tinea; and in this sense the term is used even by Plenck. But, by the greater number of writers of the eighteenth century, it was separated from favus and tinea, and considered as synonymous with porrigo larvalis ; of which disease, however, Bateman, as well as Biett, is of opinion that achores do not constitute the elemen- tary form. We are disposed to think that Alibert, in distinguishing from that affection a disease, tinea mucifi.ua, which had generally passed under the same name, has removed a difficulty which might have been inconvenient to pathologists, and has pointed out the disease to which the achores most properly belong. According to the definition of Willan, "Achor is a small acuminated pustule which contains a straw-coloured matter, having the appearance and nearly the consistence of strained honey. It appears most frequently about the head, and is succeeded by a thin brown or yellowish scab." The matter contained in the pustules does not concrete and form a crust, but the pustule breaks and is succeeded by small circular ulcerations, from which a thin glutinous or oily mucous fluid exudes, sometimes in considerable quantity, and sometimes forming white or yellow seabs, more or less moist. The achor is distinguished from the other pus- tules as follows : — from the psydracium, by being more elevated, more distinctly circumscribed, and less generally grouped and confluent; from (he favus, by being smaller but more pointed, and by not being followed by the characteristic yellow sulphur-coloured indented scab (deprimies en go- det) which explains and describes the term ; from the phlyzacium, by being smaller and destitute of its elevated and inflamed circular base; and from the varus, (which, for reasons hereafter to be assigned, we shall include amongst the pus- tules) by being succeeded by a scab or ulcer in- stead of a tubercle. Achor is a cutaneous affection peculiar to in- fancy and childhood, and constitutes the elemen- tary form of some porriginous diseases; but at thar period of life occasional eruptions of achores appear from time to time without amounting to a disease. ' These seem to be connected with a plethoric state of the body in general, or of the abdomen in particular, or with derangement of the alimentary canal, and frequently co-exist with a disordered state of the urine. They are most effectually both relieved and prevented by mild alterative doses of the pulvis hydrarg. cum creta, followed by small doses of rhubarb, with either soda or magnesia. rp_ j< ^odd. \y ACNE.—By this term is understood a chronic affection of the skin, characterized by small pus- tules, generally distinct, having their base more or less hard and of a deep red colour, which, after the suppuration of the pustule, generally imperfect, becomes a small hard, red, circumscribed tubercle, almost indolent, suppurating or resolving always very slowly. Among the best writers on cutaneous diseases there exists a difference of opinion as to the class to which acne most properly belongs, arising not so much from the difficulty of determining the nature of the vari, as from observing them in the different stages of their progress. Pienck, Willan, and Bateman, considering them as tubercles, have placed the diseases of acne in that class, whilst Alibert and Biett have arranged them with the pustular diseases. Any one who has observed the progress of this eruption with sufficient at- tention, will be disposed to coincide with the last- named authorities; for the circumscribed indu- rations, or tubercles, which are so constantly observed in this affection, are the consequences of pustules, and do not constitute the elementary form of the eruption. Whilst pathologists have been divided upon the form of this eruption, another difference has arisen concerning the seat of it, whether it is a disease of the cellular texture of the corion, or peculiar to the sebaceous follicles, originating in their obstruc- tion and inflammation. This latter cause »f the pustules of acne had not escaped the observation of Willan, for he has made it the characteristic of his second species, acne punctata; and Alibert has also noticed the disorder of the sebaceous glands as a source of similar eruptions ; but Mr. Plumbe, in describing this as constantly and exclusively the process of the formation of the pustule of acne, has given an extent to that opin- ion which is not borne out by fact In justice, however to this writer, we must not withhold th« following dissection of a case of acne rosacea, by Gendrin (Histoire Anatomique des Inflamma- tions) : "A man of fifty-five years of age, who died of an organic disease of the stomach, was, at the same time, affected with acne rosacea, which occupied the surface of the nose and almost the whole of the cheeks. The day after his death the seat of the eruption was of a bluish red colour, and incisions showed the skin to be thicker and more dense than in the natural state. On the surfaces of the incisions a number of small round red- coloured bodies were observed, which, examined by the lens, appeared to be sebaceous crypts, evi- dently double their natural size. On the surface of the skin were also to be observed the orifices of these crypts, more dilated than in the healthy state, from which a yellow caseous fluid might be squeezed. In the rete mucosum of Malpighi was seen a closely reticulated structure of blood-ves- sels, of a violet-red colour, and the corion gene- rally was much increased in vascularity. Exter- nally the skin was unequal and elevated by small round grains, which were felt more distinctly when a detached portion of the skin was pressed between the fingers. These bodies were produced by the developement and induration of the seba- ceous follicles. The general tenacity of the skin was considerably diminished." Notwithstanding the proof apparently afforded by this dissection, we are convinced that the emphragma sebaceum is not the most common cause of the pustule of acne ; for, although one sometimes finds, particu- larly on the face and chin, small pustules which are caused in this way, and from which, after the pus has been evacuated, a small oval body, formed of indurated sebaceous matter, may be expressed; and although a morbid accumulation of this mat- ter is observed in several cases of acne, yet all this is far from proving that this state of the follicles is essential to this form of pustule. And, there- fore, we very often see individuals whose follicles are in this state, without presenting any trace of ACNE. 47 acne; whilst, on the contrary, we see acne unac- companied by this state of the follicles ; and when they do become complicated together, we never see the infarcted follicles become true pustules of acne ; for, by compressing the latter at the period of suppuration, pus is easily made to escape, and not indurated sebaceous matter. Nor is it correct to say that the seat of acne is always coincident with that of the sebaceous follicles; for, though this may be true as regards the nose and forehead, the contrary is the case in other parts where these glands most abound, as at the orifice of the meatus auditorius externus, in the axilla, or in the parts surrounding the nipple, the anus, and vulva.. Acne is a cutaneous disease which is pretty steady and constant in its character, and not like many other cutaneous affections, apt to change its elementary form for that of another, or to be fre- quently complicated with other eruptions ; except that in one species of this complaint (acne indu- rata) the vari approach to the nature of furunculi, and in another (acne rosacea) there is a tendency to erythema. We have also sometimes observed acne upon the face to co-exist with eczema, par- ticularly of the extremities, the hands or legs. The opinion which we hold of the nature of the elementary eruption of acne will lead us to modify the classification of Willan, by placing this disease in the order of pustular diseases, and by adding varus to the varieties of pustules. In the subdi- vision of the genus we have little alteration to propose, except that we should prefer acne folli- cularis to acne punctata, as explanatory of that species of the disease ; and that as it is our inten- tion to distribute the syphilitic eruptions according to their external characters, considering the form of the eruption to be determined more by pecu- liarity of individual constitution than essential to the nature of syphilis, we shall have occasion to subjoin another species. Were this classification perfectly natural, mentagra, or sycosis, ought to find its place in this genus; but not wishing to introduce any innovation in the arrangement which can be avoided, we shall follow Willan and Bate- man in considering it apart. This genus will, therefore, consist of the following species :— 1. Acne simplex, 3. Acne indurata, 2.-----follicularis, 4. -----rosacea, 5. Acne syphilitica. 1. Acne simplex,—Syn. tovQoi (Grec); Vari (Lot.) ; Psydracia acne (Sauv.); Gutta Rosea hereditaria (Darwin) ; Dartre pustuleuse miliare (Alibert) ; Die Finnen (Plenck.) This species consists in an eruption of small vari, appearing chiefly on the face, temples, or forehead, upon the shoulders, the upper part of the back, or breast. These pustules, which are not numerous, are generally observed to succeed each other. They go through their course sepa- rately, without any symptom of constitutional disorder, and generally without any local pain, heat, itching, or uneasiness, so that it is not un- common to meet with people having a considera- ble eruption of vari upon the back, without their being aware of it. These pustules first appear under the form of small inflamed points, which are felt in the skin like small hard seeds, about the size of a pin's head ; they continue to enlarge for three or four days, and about the sixth or seventh day they attain their greatest size, when they are red, smooth, elevated, and somewhat acuminated. They are hard, but seldom painful to the touch. After two or three days more, a small speck of yellow matter appears on the apices of some of the pustules ; when these break, a thinner mattei is secreted which soon dries into a thin yellowish scab. After the suppuration is finished, (which, in proportion to the size of the pustule, is always inconsiderable,) and the scab separated, there still remains a red point, a little elevated, which only disappears very gradually. At other times the redness and swelling continue, and if that is the case with a considerable number of the pustules, whilst new ones are appearing, the disease ap- proaches more or less to the acne indurata. Or when the disease has continued some time, a gen- eral redness and roughness of the intermediate skin takes place from the coalescence of the in- flamed areolas of the pustules. Sometimes, however, instead of the pustulei' appearing in succession, a considerable number of them break out simultaneously, covering almost the whole surface of the forehead ; a circumstance which is most frequently observed in young fe- males. And when the pustules exist in a consid- erable number, the sebaceous follicles appear to suffer a certain degree of irritation, for the skin has an oily shining surface ; suppuration is retard- ed, and the pus is smaller in quantity, and a very thin scab forms, which separates so quickly that it is sometimes not observed : or, at other times, and more especially when the eruption is seated upon the back or shoulders, the suppuration in more abundant, and the scab is thicker, but soon detached by the friction of the linen. This eruption, very correctly delineated in Bate- man's LXII. plate, and in the 23d of Thomson's Atlas, is very inadequately represented in the 22d Plate of Alibert's splendid work. The acne simplex, which is rare before puberty, occurs chiefly in young people about that age, and is very common in young females on the first ap- pearance of the catamenia. In some individuals this eruption continues for some time to recur, or to become more troublesome at the menstrual pe- riod, and is not an unusual attendant upon dys- menorrhoea: in others, who have it partially, it frequently returns at short intervals ; but in others, who are more strongly predisposed to it, it is more extensive, and never wholly disappears, being more or less troublesome at uncertain periods. It is a disease, even when present in a very consid- erable degree, perfectly consistent with the enjoy- ment of good health; for which reason it was formerly considered a salutary effort of nature to relieve the constitution. Many people experience a decided relief in disorders of the digestive or- gans on the appearance of vari; so that, on many occasions, they seem to be critical. And Bate- man observes that severe indigestion, or continued pains in the stomach, have been immediately re- lieved after an eruption of vari; in which instances there is occasionally also an eruption of liche- nous papuls on the body and limbs. It appears, however, to be most closely connected with an imperfect performance of the functions of the womb, with a constipated state of bowels, or a sluggish state of the secretion of the liver; and hence the vari have sometimes been called atra- biliary pustules. It does not, like many other cutaneous diseases, depend upon irritation or an irritable state of the mucous membranes of the 48 ACNE. alimentary canal, but more often co-exists with an ] atonic state of the digestive organs. But what-1 ever may be the pathological condition of the body upon which it depends, the cause which has un- questionably the leading influence upon this com- plaint is hereditary predisposition. Sedentary ha- bits, an indolent manner of living, extremes of diet, spare as well as rich, and anxiety of mind, tend to confirm this predisposition; and wherever it exists, trifling causes are sufficient to excite the disease. Amongst these may be mentioned errors of diet; excesses at table ; violent exercise in hot weather, or in heated rooms, especially when fol- lowed by cold drinks ; eating cold raw vegetables, as cucumbers, turnips, melons, when the body is much heated ; exposure to the heat of the sun or of the fire ; the application of irritating cosmet- ics ; vexation of mind, bursts of passion, or any strong mental emotion. It would be difficult to mistake the eruption of acne simplex, in its pure state, for any other cuta- neous affection. Ecthyma is the disease which, in appearance, it most resembles ; but the vari of acne may easily be distinguished from the phlyza- cious pustule of that disease by their smaller size, by their slower progress, and by their base contin- uing indurated after suppuration : whilst the pus- tules of ecthyma are large and superficial, never accompanied with chronic indurations, and form thick scabs more or less prominent. When the eruption of acne simplex has frequently recurred in the same part, as on the nose or forehead, the skin takes on a general appearance, which, by an inexperienced observer, might be mistaken for a pustular or the small tubercular syphilitic erup- tion ; but the particular red copper-coloured areola, and the disposition of the syphilitic tubercles to ulcerate upon their summits, will easily distinguish them ; whilst the concomitant constitutional symp- toms clear up all doubts which might arise. Bateman has undoubtedly been guilty of an oversight in considering the acne simplex as a local disease, and leaving it to be treated chiefly by external applications. But in this opinion he is, indeed, almost solitary ; for the united experi- ence of the best observers is against him. Like almost every affection of the skin, when long seat- ed in any part, it may persist as a local disease ; but in its origin it is strictly symptomatic, and is invariably aggravated by any disorder of the func- tions of those organs in which it has its source. When the pustules of acne simplex are few in number, they scarcely deserve any attention, ex- cept as symptoms of some constitutional derange- ment ; but when they are considerable, they re- quire the use of different medical measures, as well general as local, on their own account. When the disease appears to be connected with an unsat- isfactory discharge of the uterine functions, the treatment must be directed to this object. In young persons of a strong and plethoric constitution, and particularly if about the first appearance of the catamenia, a small bloodletting will afford the most immediate relief; or, if there is pain of the back or loins, a few leeches may be applied to each groin, the feet may be immersed in a warm salt- water pediluvium, and the bowels preserved in an open state by some cooling saline aperient, as the sulphate of magnesia dissolved in infusion of roses, and acidulated with diluted sulphuric acid, or the sal polychrest in combination with very small doses of rhubarb. When the patient is more deli- cate, the sulphur lotum in combination with mag- nesia and rhubarb affords a very safe and satisfac- tory remedy. It is conveniently administered as follows: —R Sulphur, loti, magnesias ia p.; Pulv. rhei. 3i.; Pulv. rod. glycyrrhiz. ^ss. Fiant pulveres sex, quorum unus bis terve die sumendus. To this may be added the use of five grains of the pil. aloes cum myrrha. at bed-time; or, if the patient is pale, and the circulation lan- guid, small doses of the sulphas ferri may be com- bined with the aloetic pill. If the eruption is ex- tensive or obstinate, five grains of the pil. submu- riat.- hydrargyr. comp. may be taken at bed-time, instead of the aloetic pill. The diet should be light, cooling, and easy of digestion; and wine and all heating drinks should be abstained from. The same general treatment is applicable to young male subjects ; a small venesection, cool- ing saline aperients, the powder of sulphur, mag- nesia, and rhubarb, and, if necessary, a few grains of Pluminer's pill, and a course of decoction of taraxacum, with a little sulphate of potass. In both cases, after the aperient and alterative reme- dies, the diluted mineral acids are useful reme- dies. The best local application to the eruption in the early stage is decoction of bran, decoction of the seeds of cucumbers or melons, or the emul- sion of bitter almonds. It is not until the erup- tion has declined and become chronic, that gently stimulating applications are required, and they are then of much use. The effect of any irritating lotion used in the early state of the eruption, is to multiply the pustules; but after suppuration, when proportioned to the sensibility of the local affection, they are often of the greatest use. Nor in this period of the disease need there be any ap- prehension of producing internal disorder by the sudden repulsion of these cutaneous eruptions; it is only in the early and active state of the dis- ease that headache and disorders of the digestive organs have sometimes been thus produced. The milder, but sometimes not the less efficacious, lotions for this purpose are sulphurous mineral waters, a weak solution of sulphuret of potass, (K Potassii sulphureti gi.; Aquae f.Oi.) or the lotion which is made by pouring a quart of boiling wa- ter upon an ounce of sulphur, and allowing it to infuse twelve or fourteen hours. When the erup- tion is extensive, the same preparations may be used in general baths at 96°, (R Potassii sulphu- reti |iy.; Aq. c. c. fiat balneum.) Lotions, containing alcohol, afford very satisfactory appli- cations^) this eruption. (R Aqux rosae Oss.; Alco- hol, f.gii.; fiat lotio.) The proportion of spirit must be diminished or increased according to the excitability of the skin ; but it must not be for- gotten, that a slight increase of inflammation is often advantageously excited by the first applica- tion of a moderate stimulus; that this transient irritation is overcome by persevering in it; and that, in this way, the skin acquires the power of bearing an increased degree of stimulus. The efficiency of alcoholic lotions is sometimes in- creased, by the addition of a little of the liquor ammonia? acetatus, or acetous acid, or subcarbo- nate of ammonia. The muriate of ammonia, in lotion, is sometimes very useful in chronic cases of acne simplex. (R Aquae rosae Oss.; Alumi- nis Jiii.; Ammonias muriatis Jji.; Potassii sul- ACNE. 49 phurcfi ^i; ft. lotio.) When stronger irritating remedies are necessary, which is, however, seldom the case, muriate of mercury, in small quantities may be added to the alcoholic lotions. (R Aquae dest'.llnt. Oss.; Alcohol. f.§i.; Hydrargyri chlorid. eorrosiv. gr. vi.ft. lotio.) It sometimes happens, that in old cases of acne simplex, much benefit is derived from exciting an inflammatory state of the eruption. Bateman mentions a lady who con- sidered herself much benefited, after a severe inflammation, and even excoriation of the face, which had been produced by a poultice of bruised parsley. But it is seldom necessary, in this spe- cies of the disease, to have recourse to the remedy of Ambrose Pare, revived by Darwin, who affirms that blistering the whole face, in small portions successively, is the most effectual remedy for the inveterate forms of this acne. The ancients, in the treatment of vari, chiefly relied upon external stimulant applications. These consisted of lotions and liniments, containing vinegar and honey, sometimes combined with an emulsion of bitter almonds, and sometimes with resin, myrrh, turpentine, and other gums, with alum, soap, and Cimolian earth ; or the bruised roots of the lily, cyclamen, and narcissus. But the fruit of the wild vine (labrusca) is the appli- cation which Pliny (Hist. Nat. lib. xxiii. cap. 14,) mentions as most especially useful. 2. Acne Follicularis, Maggot Pimple. Syn. Acne punctata (Willan) ; lovdos (Greco- rum); Varus (Latin); Crinones, Crimones (Va- riorum Auct.); Grutum milium (Teutonice); Der Gries (Plenck); Punctae mucosa? (Darwin); Grubs (Anglice); Tannes (Gallicd). Pustules, having the precise character of vari, are observed to have their seat in the sebaceous follicles ; sometimes originating locally from the accumulation and induration of sebaceous matter, causing their obstruction (emphragmasebaceum); and sometimes symptomatically, from inflamma- tion of the follicles, arising from some disorder of the internal organs. When the vari are produced by the first named cause, the sebaceous matter, by being exposed to the air at the mouths of the fol- licles, assumes a black appearance, and the pus- tules present a black point on their summit, sur- rounded by a very slightly raised border of cuticle. This circumstance, which gives sometimes a par- ticular feature to the disease, afforded Willan the specific character of acne punctata,- but for which as this appearance is far from being constant, and as pustules have their seat in the follicles without presenting it, we have substituted acne follicularis, as better explaining the nature of the affection. A loaded and obstructed state of the sebaceous follicles may exist to a considerable extent, with- out inducing inflammation ; and only very minute hard white tubercles, of the colour and size of millet seeds, are to be observed, from which the sebaceous matter being pressed out through the circular orifice of the follicle, takes a filiform shape, bearing a close resemblance to a maggot. That it really owes its form to the manner in which it is forced through the aperture of the follicle is obvious ; for, if the black spot is ruptured by a fine needle, it will be seen to be a mere deposition of sebaceous matter of a r,>und form. In this state they are commonly known by the name of crinones, worms or grubs. [Recently, it has been found, that these follicles are occupied by a para- Vol. I__7 e sitic insect, (Acarus folliculorum,) which has been found alone or in clusters of several in a single follicle. In the perfectly healthy state of the follicles, they are few in number; but when sebaceous matter, which seems to serve them for aliment, is allowed to accumulate, they abound. The insect was first observed by M. Simon, of Berlin, and has been since seen and described by Mr. E. Wilson, in his work on Diseases of the Skin.] As the matter accumulates and hardens, it becomes a source of local irritation, and the sebaceous crypts, in consequence of distension, inflame and form pustules, which suppurate im- perfectly. At other times these obstructed follicles remain stationary, without ever passing into the inflammatory state; or the accumulation of the matter goes on increasing until they form con- siderable follicular tubercles, resembling those of molluscum,and sometimes tumours of considerable size, or, occasionally inflaming, assume the ap- pearance of indolent boils. The disposition of the body to the accumula- tion of the sebaceous matter in the follicles of the skin is much dependent upon peculiarity of con- stitution, but is always very intimately connected with a constipated state of the bowels, so that in many individuals the necessity for aperient medi- cine is indicated by the sebaceous follicles appear- ing full or prominent. Besides this origin of follicular vari, they may also be produced directly without any collection of sebaceous matter either by local irritation, in which way some kinds of cosmetics seem to act, or by inflammation of the follicles arising sympto- matically from the irritation of the internal organs, as the bowels or the womb. The follicular may often be seen mixed with the simple vari in this and the other species of acne. Of this complication there is a very accu- rate delineation in Bateman's LXII. plate. For the removal of follicular vari, besides the general treatment of acne simplex, which is also applicable here, it is necessary to empty the folli- cles by mechanical means, either by pressing on both sides of the pustules until the hardened matter is sufficiently elevated to be taken hold of, or by employing a blunt curved forceps for this purpose. But when this state of the follicles exists, to a considerable extent, nothing so effec- tually empties them and clears the skin as the vapour bath, followed by the warm sulphurous bath. Lotions of sulphuret of potass, with or without alcohol, are of great service when the disease is of small extent. When the disease has subsided, and the state of the skin admits of it, general friction with the flesh-brush, a flannel glove, or a coarse towel, is of great use. The internal remedies most suitable in this complaint, are powders of sulphur, magnesia, and rhubarb, with an occasional saline aperient. Dr. Under- wood recommended the use of a solution of car- bonate of potass internally, and Dr. Willan was [ in the habit of occasionally prescribing the oxy- muriatic acid ; and there can be no doubt, that any other medicines which improve the functions of the digestive organs and benefit the general health, have a considerable influence in correcting this unhealthy state of the skin. It is probably in this way that the following alkaline tonic, recom- | mended by Dr. A. T. Thomson, produces its ' effects; (R Zinci sulpkat. gr. xxiv.: Liquoris 50 ACNE. potassae f.^xii.; solve. Sumantur guttae xxx. ex cyatho aquae bis quotidie.) 3. Acne indurata, Stone-pock. Syn. AifliJXiKts (Hipp.) ; Vari (Latin) ; Dartre pustuleuse disseminee(,4/2ier/); Pustulas solitarise (Teutonice); Eiterfinnen (Plenck); Pustulse in- flammatoriffi (Lorry). In this species the vari are larger, less regular in their figure, sometimes ovate as well as conoidal; they are deeper seated ; the inflammation of the surrounding skin is more extensive ; suppuration takes place still more slowly, and is followed by thicker scabs and by partial indurations, more or less considerable, in the subcutaneous cellular tissue as well as in the skin. It attacks the face most commonly, but is also very frequently ob- served upon the upper part of the back, shoulders, and breast, and has sometimes been seen to cover the whole posterior part of the trunk. It affects chiefly young adults of both sexes, but the severest cases are met with in young men. It affects most generally persons of gross phlegmatic tempera- ment, who have a thick greasy skin : and though the strong and robust are more frequently the subjects of its attacks, it does not spare the weak or exhausted. We have certainly observed it more frequently in patients of a scrofulous habit than in others. We have known it co-existing with a strong family predisposition to mania; and it has been observed in connection with the he- morrhoidal constitution and pulmonary consump- tion. It is sometimes accompanied with symp- toms of abdominal derangement; but it is also sometimes the only discomfort of people enjoying, in every other respect, perfect health. In persons predisposed, it is generally excited by irregularity of diet, by cold food or drink when the body is heated, and sometimes it is developed by external irritating applications, as a blister. This complaint presents itself in very different degrees of intensity. Sometimes it is very slight; a few red inflamed points show themselves in the forehead, temples, the upper part of the cheeks, or over the angles of the lower jaw ; these become pustules of a bright rose colour, which, rising slowly, only after two or three weeks, end in sup- puration, or sometimes never arrive at that state. The pustules when red are sore and tender to the touch, but as they decline they become livid and less painful. These are succeeded by other pus- tules. After suppuration, the hkin on which they are seated remains hard and of a bright rose red, and the subcutaneous cellular tissue assists in forming tubercles, or chronic indurations. In this manner, a certain number of pustules having suc- ceeded each other, the affection gradually sub- sides. But, in general, the disease is much more severe ; the whole face is covered with irregular bright red pustules and livid red tubercles ; they are particularly large and numerous on the rami of the lower jaw and under the jaw ; on the temples and cheeks ; and smaller but not less thickly spread upon the nose and forehead. These tubercles themselves often suppurate, forming superficial indolent abscesses covered with skin of a livid red colour. They seldom point or find issue for their contents spontaneously, but occa- sionally require to be discharged by the aid of the lancet, and then the wound heals slowly, leaving a livid indented mark, which never disappears. The intervals of the tubercles are studded with pustules in different stages of their progress, either just beginning to appear, in a state of suppuration, or covered with a scab, with red spots distributed amongst them, so as sometimes to give a general red appearance to the whole surface of the skin. Occasionally a number of black points, marking infarcted mucous follicles, or true follicular vari, are to be observed, here and there, in the intervals between the tubercles and pustules, but chiefly upon the sides of the nose, cheeks, and forehead. The skin is greasy and shining, and the whole face much swollen and inflated, giving the patient a most disagreeable aspect, which is very accu-' rately represented in Bateman's LXIII. plate. The pustules of acne indurata often leave traces which it is impossible to efface, the skin being marked with many very small scars, the effects of former eruptions of this complaint, more or less frequently repeated. Though this species of acne attacks frequently both the face and back at the same time, it some- times spares either one or the other, but in either case the disease is of long duration and tedious ; and whether it terminates spontaneously or by the power of art, the process is only completed very slowly, and patients remain very liable to a re- lapse. Notwithstanding the severity of the eruption, the patient may enjoy good general health, and attend to all his wonted avocations, unless he may have to complain occasionally of headach, or a disagreeable sense of heat in the face ; and it has been observed, that if a fever, or other severe dis- ease, should take place, the eruption often sub- sides or disappears ; so that its recurrence under such circumstances is to be deemed a sign of returning health. Bateman has seen the erethism of a mercurial course, administered for other pur- poses, occasion the disappearance of this acne, which returned with the restoration of flesh and strength, after the omission of the medicine. And we have observed that in those cases in which the disease is compatible with otherwise good health, it is also invariably the most difficult to cure. When acne indurata is severe or of long dura- tion, it is a disease most difficult to subdue, and often resists the most skilful and the most perse vcring treatment. If the eruption is sudden 01 extensive, and appears in a subject of sufficient strength, nothing makes so decided an impression upon it as venesection ; and, even in delicate sub- jects, advantage may be derived from the detrac- tion of a few ounces of blood. In the inflamma- tory state of the disease, cooling saline purgatives, with a mild alterative mercurial pill at bed-time, and the antiphlogistic regimen form the essential parts of the constitutional treatment. As the disease declines, or becomes chronic, the mineral acids are often used with great advantage ; and the internal use of the sulphureous mineral waters, as those of Harrogate, are amongst the most suc- cessful remedies. Dr. Bateman thinks that ad- vantage has been derived from the internal use of small doses of soda, sulphur, and antimony, assisted by proper external treatment. Neither purgatives nor the antiphlogistic regimen should be continued longer than the first active state of the disease. On the contrary, it is frequently of ad- vantage to have recourse to mild tonics and alkalis; and, on the same occasions, the greatest bev*fit ACNE. 51 has been derived from changing from a poor to a more generous diet. Lorry relates the case of a water-drinking monk, whom he relieved of this complaint by the moderate use of wine. The constitutional disease with which this complaint appears to be most connected is atonic dyspepsia, with a constipated state of bowels ; it is, there- fore, obvious that a plain moderate diet of animal food is more likely to agree than raw vegetables, cresses, and vegetable acids, used under the notion of correcting the scorbutic state of the humours. [In some obstinate cases of the different forms of acne, great benefit has resulted, as in other chronic cutaneous cachexies, from a thorough change of diet, and especially from putting the patient on the use of saccharine matter between the meals, so as to modify the condition of the chyle, and through it that of the blood and of the tissues. An ounce and a half of simple syrup may be given with this view about three hours after each meal. With the syrup may be associated the iodide or ioduretted iodide of potassium, in the form of the liquor iodini compositus (gtt. x—xx ter die). By a perseverance in this course for eight or ten weeks, some very obstinate cases have yielded, See Dunglison's Practice of Mcd'.cine, Id. edit., p. 129. Philad. 1844; and his Ele- ments of Therapeutics and Materia Medica, Vol. 2, p. 315. Philad. 1843.] But constitutional treatment would be of little avail without the assistance of local means for accelerating the progress of the pustules, or for promoting the resolution of the tubercles. In the early stage of the eruption, mild emollient appli- cations are most suitable, such as demulcent decoctions or poultices, which, if there is pain, may be made with the decoction of poppy heads. When the pustules have suppurated, and are slow in discharging themselves, it is advisable to apply to them, as Turner recommends, the common principles of surgical treatment. After the pus- tules have discharged their contents, either spon- taneously, or by means of the lancet, stimulating alcoholic lotions, containing a small quantity of corrosive sublimate, are chiefly to be relied on, 6uch as have been mentioned for the severer cases of acne simplex. In the hospital of St. Louis, at Paris, the greatest advantage has been derived from rubbing the pustules, as well as the tuber- cles, with the following ointment: R. Hydrar- gyri ammoniat. 9i. ad ^i.; Adipis, jfi. But of all the preparations for promoting the resolu- tion of the tubercles of acne indurata, none are, according to M. Biett, to be compared to the iodide of sulphur, mixed with lard. (R. Sul- phur, iodid. gr. xii. ad gr. xxiv.; Adipis, ^i.) M. Biett employs this remedy in the wards of the Hospital of St. Louis with decided benefit. In some severe cases of acne indurata submitted to the friction of ioduret of sulphur, the tubercles were resolved with astonishing rapidity. But the good effects of all these means are very much promoted by the use of the vapour bath, and more especially of the douche of vapour, directed for twelve or fifteen minutes upon the eruption. It is principally in old chronic cases of the acne indurata, where the local affection has completely established itself, that it may sometimes be neces- sary to have recourse to means for changing entirely the action of the part ; and for this pur- pose, blisters, used by Ambrose Pare, under the notion of drawing out the peccant humours, and revived by Darwin, have been frequently used in the Hospital of St. Louis, and have been found eminently useful. [Solid nitrate of silver has been rubbed over the parts, and they have been brushed over with one of the concentrated mineral acids with a similar object.] During any recurrence of a considerable fresh eruption, the means adapted to the chronic state of the disease must necessarily be suspended, and recourse had to the constitutional and local means suited to its inflammatory state. M. Biett has found that when the disease has disappeared, a lotion, or douche of cold sulphur- ous water is of great use in establishing the cure, and in preventing a return of the eruption. 4. Acne rosacea, carbuncled face. . Syn. Zhiov (Grec.) ; Varus (Roman) ; Gutta rosea et rubedo (Aucforum) ; Gutta rosacea oenopotarum et hydropotarum (Teutonici); Kup- ferbandel (Plenck) ; Bacchia (Linn.) ; Gutta rosea hepatica (Darwin) ; Herpes pustulosus gutta rosea, Dartre pustuleuse couperose (Ali- bert) ; Ionthus corymbifer (Good); Saphirs, Goutte rose, couperose (French) ; Roth-gesicht, Roth-nase (German) ; Red pimpled face. In a correct pathological nomenclature, as the last species might with greater propriety be term- ed acne furunculus, being a complication of the varus with phlegmon, or inflammation of the subcutaneous cellular tissue, so this species would be more accurately distinguished under the name of acne erythema, the pustules of acne being combined with an erythematic inflammation of the skin. In this respect, as regards the local or external disease, acne rosacea differs from the other species, the vari sometimes preceding and developing the erythema, and the erythema, on the contrary, being sometimes the occasion of the vari. From this circumstance has arisen the dis- tinction of gutta rosea, observed by Nicolaus Florentinus, Ambrose Pare, Astruc, and Plenck, dividing it into species, under the terms of sim- plex, or pure erythema,—pustulosa and bacchia- lis, the acne rosacea of Willan, — and squamosa ulcerous and varicosa, the sequela? of obstinate forms of that disease. The nose is, commonly, the first seat of th"~i affection. In persons predisposed, who are gen- erally of the middle age, after any exciting cause, as a full meal, heating drinks, or indigestible sub- stances, the extremity of the nose becomes of a deep red colour, more or less intense, which at first gradually subsides with the removal of the exciting cause; but, at length, by repetition, grows to be habitual. In this red shining ap- pearance of the nose, some elevated points of a brighter red colour, sometimes distinct, sometimes in groups, are afterwards observed. These points enlarge, becoming pustules, which suppurate at their summits; but the suppurative process is always imperfectly established, forming seldom more than a small white acuminated point on the apex of tjhe pustule, which makes a striking con- trast with the dark damask red colour of the pus- tule, an appearance which is well represented in Alibert's XXI. plate. This white point of the pustule bursts and forms a thin white scab, which, detaching itself, leaves beneath it a hard phyma- tous tubercle. These pustules succeed each other, and in this manner the disease perpetuates itself. 52 ACNE. Sometimes the disease is confined exclusively to the nose, which, from the repetition of this mor- bid process, and the successive formation of tuber- cles, increases very considerably in size, being covered with knobs and asperities, whilst the blood-vessels of the surface of the skin are seen enlarged, and the small veins appearing varicosed, have the appearance of bluish lines, strongly con- trasted with the general red colour of the surface ; or the intermediate skin is striated with reticula- tions of enlarged cutaneous veins, resembling an injected membrane, an appearance which is cor- rectly delineated in Buteman's LXIV. plate. M. Alibert thinks he has observed, that the right side of the nose is more liable to be affected with this species of acne than the left, a circumstance which he connects with the influence of the state of the liver upon this disease. More generally the size of the nose is not increased, but its form only altered ; and the disease extends itself to the cheeks, forehead, and chin, so as sometimes to cover the whole face. The red colour of the skin, which is always more remarkable after dinner, or in the evening, than in the morning, is not any- where equal in degree, but is always more so in the seat of the pustules. The disease may cease and return in different degrees of intensity ; but after it has continued for some time, the surface of the skin becomes uneven and rough, and if the disease should even disappear, the skin never entirely recovers its natural state. In general this eruption produces little discom- fort of feeling in proportion to its deformity, sel- uom more than a slight momentary itching; but some persons have the face in a very irritable state, with the sensation of heat and burning, being frequently obliged to bathe the face in cold or tepid water for relief. After eating, drinking, or any moderate exercise, they feel a sudden glow of heat in the face; but it is chiefly when they approach the fire that they suffer most; it pro- duces in them a sensation of pungent heat, or of burning and itching. Hereditary disposition is, unfortunately, one of the most common predisposing causes of this dis- ease, and one which sometimes invcterately ad- heres to many successive generations. Alibert traced the disease, in one family, through four generations. This predisposition frequently shows an affinity with that of scrofula, but is always in- timately connected with the state of the functions of the abdominal viscera, and hence causes tend- ing to establish an unhealthy state of these is liable to induce this predisposition. Fortius rea- son, the indulgences of the table, in eating as well as in drinking, violent emotions, or long and intense exertions of the mind, sedentary occupa- tions, and much watching, are amongst the most frequent causes of it. Persons of middle age are consequently most liable to it; and it is most fre- quent in men of a hemorrhoidal constitution, and in women at the critical period of life, or in such as suffer from disorder of the uterine functions. Notwithstanding the difference of habits, it seems equally common to both sexes. Sometimes it shows itself, or is increased, during gestation ; but in other circumstances, it has been observed to disappear during pregnancy, and return after parturition. Besides these- causes, anything which favours or determines the afflux of blood to the head, increases the tendency to this complaint. It will, therefore, be easy to understand, from the causes just assigned, why it should be met with amongst men of letters, lawyers, merchants, and gamesters, and in public offices ; among women employed in drawing, painting, and tambouring; and in those whose avocations oblige them to keep the head in a depending position. It is not, however, to be forgotten, that the acne rosacea sometimes appears in people of the most sober and temperate habits, and that it sometimes shows itself in conjunction with a state of exhaustion and general debility. In people predisposed to this complaint, either hereditarily or by habits of life, it may be imme- diately excited by local irritation, as by long ex- posure to a hot sun, to the heat of the fire, or the application of strong cosmetics. Violent exer- cise, bursts of passion, or fits of chagrin, are also capable of developing it. Alibert mentions the case of a lady, who, having been entirely cured of the complaint during a methodical treatment of it at the establishment at Tivoli, on receiving some afflicting news, in the course of twelve hours relapsed into a state worse than ever. But it most generally makes its appearance after errors of diet, of which, when the predisposition is strong, any moderate degree is sufficient to pro- duce it. These exciting causes explain why it is so generally met with amongst cooks, glassblow- ers, mowers, couriers, and players. This complaint is, frequently, a symptom pre- cursive of diseases of the liver, but sometimes they coexist contemporaneously. It seems gen- erally to depend more upon a state of abdominal plethora, or congestion of the liver, than upon any irritation or irritable state of the mucous sur faces of the alimentary canal; and hence spongy bleeding gums, and habitually torpid and con- fined bowels, are its usual attendants. The treatment of acne rosacea demands great perseverance, and even in spite of this, it is fre- quently unsuccessful. To every form and variety of this complaint, with few exceptions, one part of the treatment is generally applicable and essen- tial, and it is that which consists in a strict ad- herence to proper diet and regimen, adapting them as much as possible to the correction of that state of body which constitutes the predisposition, and avoiding all those causes which have the power of exciting it. These views will be attained by leading a sober temperate life, by using a mild diet of easy digestion, by avoiding excesses at table, by abstaining from spirits, liquors, and sometimes even wine ; by avoiding hot fires, heat- ed apartments, and violent exercises, and by en- deavouring to eschew violent emotions of mind or close applications of the understanding. The power of this plan will be increased, and the general object promoted by the use of appropriate remedies, suitably adapted to the peculiarities of the case. If much local inflammation be present with general plethora, a moderate venesection may render great service. If the eruption is con- nected with the suppression of any accustomed evacuation, the propriety of endeavouring to re- store it naturally suggests itself; if the menstrual function is laborious, imperfect, or irregular, the I proper modification of the method of cure readily | occurs ; if a congestive state of the liver is pre- | sent, or when the liver is more severely affected, \ mi!d alterative remedies — as Plummer's pill. ACNE. 53 taraxacum, and sulphurous mineral waters, as those of Harrogate, are applicable. These last are of known efficacy, and are much to be pre- ferred to the saline mineral waters. In all cases an open state of the bowels is of importance, but much purging is generally detrimental. We have great doubt whether any constitutional remedy has a specific action upon the local disease. In France and Germany the dulcamara and viola tricolor have been much used; but we think that, united with the general treatment, more benefit is derived from the use of the liquor potassae taken a few hours after each meal. A judiciously directed topical treatment is of great importance in the cure of this disease. In sudden and acute attacks a few leeches may be advantageously applied near the seat of the com- plaint, especially when this eruption affects fe- males at the critical period of Hie, although, in these cases, small general blood-lettings are some- times of greater service. In the same state, mild, tepid, demulcent applications are to be frequently used; amongst these the decoction of beans has always enjoyed a great reputation : and as the in- flammatory affection subsides, sulphuretted lotions form the most useful applications. If the disease is not benefited by these means, more stimulating lotions may be had recourse to, but in general they are less useful in this species of acne, and require more circumspection, for they not unfrequently aggravate the complaint. Gentle astringent lotions of alum, combined with a very small quantity of alcohol, are sometimes very useful, and in an in- dolent state of the local disease, the vapour-douche directed to the part affected, has been often found of great service; the same state also sometimes admits of moderate friction, or resolving applica- tions. It is to these cases that the remedy of Am- brose Pare, a blister applied to the diseased part, deserves consideration, a practice the utility of which has been occasionally verified in the Hos- pital of St. Louis. Nor are the general principles of surgical treatment to be neglected here ; for when the vari are seated in the follicles, the focus of irritation is removed by evacuating them. Besides these general and local means of treat- ment, the nitro-muriatic foot-bath, in the propor- tion of two ounces of the acid to twelve pints of water, has been very much recommended ; and in many diseases of the skin we have found the greatest benefit from sponging the sound parts of the skin, two or three times every morning, with a lotion consisting of two drachms of nitro-muri- atic acid, and two pints of water. It is also fre- quently of advantage to apply a blister to the arm, or to open an issue as a derivative. 5. Acne syphilitica. Si/n. Gutta rosacea syphilitica (Plenck) -, Sy- philide pustuleuse miliare (Alibert); Pustules syphilitiques psydracees (Rayer.) The multifarious forms of cutaneous diseases which have been described as originating in syphi- lis, may fairly be said to have deprived that dis- ease of any specific character, for there is scarcely a morbid appearance presented by the skin which may not, in a modified state, be found amongst syphilitic eruptions. But if any one will take the pains to examine into this matter, he will find, what might reasonably have been expected as be- ing more in accordance with the general laws of pathological phenomena, that though there are certain forms of cutaneous disease essential and peculiar to syphilis, the greater number of those described as syphilitic, depend upon the constitu- tional predisposition of the individual, modified by the syphilitic virus; and that whilst the influ- ence of this disease impresses upon them a gen» ral character, their particular form depends upon the pathological peculiarity of the individual. Thus, if lichen, lepra, or any other cutaneous dis- ease, makes its appearance in persons tainted with the venereal poison, these diseases, though origi- nating in ordinary causes, will suffer a relative modification. In proof of this, we find that the syphilitic acknowledges the same causes as the other eruptions, being excited by errors of diet, violent exercise, strong mental emotions, &c. It seems, therefore, more natural in a classification founded on external characters, to distribute the syphilitic eruptions in each genera as their exter- nal appearance would require them to be arranged, rather than to confound them together under a class of anomalous eruptions. In this way the general treatment required for this disease may be modi- fied by the peculiar character of each eruption, and the student will be led more naturally to find the place of the eruption in the classification. This is evidently the view which Plenck took of these diseases, and the plan which Willan intend- ed to pursue; but M. Alibert, as faulty in method as correct in description, has formed the venereal eruptions into a class under the name of syphi- lides, and M. Biett, to whom we are so much indebted for a more correct knowledge of many of these diseases, has omitted to correct this error of classification. They who are conversant with diseases of the skin, will find some difficulty in following Mr. Carmichael in arranging these erup- tions under his papular, pustular, phagedenic, and scaly diseases, and will be disposed to doubt whe- ther, under these descriptions, he has been so suc- cessful as to include such as are peculiar to, or characteristic of, the venereal disease. Under the term gutta rosacea syphilitica, Plenck had marked the acne syphilitica. It corresponds nearly to the disease described by Alibert, under the term syphilide pustuleuse miliare, and, by Biett and Rayer, pustules syphilitiques psydracees. It is the least common of the syphilitic pustular eruptions, and affects chiefly the face, forehead, neck, and trunk. The pustules of this eruption correspond very neary in form and dimensions to those of acne rosacea,- they are round, conical, and acuminated, surrounded with an inflamed areola, and possess the true character of vari, sup- purating only at their apex, and invariably termi- nating in tubercles. They are, however, distin- guished from them by their deep, red, amaranthine, or copper-coloured areola, by their brownish yel- low scab, and by their leaving a small, slightly depressed cicatrix. A correct delineation of acne syphilitica is still a desideratum in this branch of medicine,- but, in general, the nose, cheeks, and forehead present a livid copper colour, as if stain- ed with the lees of wine. In these discoloured patches, pustules appear from time to time, which leave behind them small dark red tubercles, chiefly on the forehead, nose, or adjacent parts of the cheeks. As the pustules succeed each other, they are to be seen mixed together in every stage of their process. With the acne syphilitica may 54 ACRODYNIA —ACUPUNCTURE. sometimes co-exist eruptions of another character (frequently scaly) upon the extremities. The acne syphilitica is always a secondary sy- philitic affection, consequent to chancre ; it is not uncommon to see it totally unaccompanied with any of the other secondary symptoms of that dis- ease, but its most usual attendants are nodes, inflammation of the periosteum, and nocturnal pains. The specific treatment of acne syphilitica, which must still be that on which every prudent practi- tioner will chiefly rely, demands modifications adapted to the general nature of acne. In the early state of the eruption it is better to pursue the means found useful in the ordinary forms of that disease, and to reserve the mercurial treat- ment for the chronic stage. By this method a much smaller quantity of mercury suffices for the cure. The action of the mercury is rendered much more efficacious when combined with a course of taraxacum or sarsaparilla. In a case of this disease, which came under our care lately, the greatest improvement was effected in the eruption by the use of sarsaparilla alone, given in powder ; in general it is more efficient when combined with mercury, and we are acquainted with no prepara- tion which fulfils this intention better than the celebrated decoction or tisan of Feltz. (R. Aquas Oxii: Antimonii sulphuret. ^iv : Rud. sarsa- parillas %\i: Hydrargyr. chlorid. corrosiv. gr. iij . Ichthyocollm §iss. The antimony to be enclosed in a muslin bag, and the vjhole to be boiled gen- tly until the water is reduced one half, except the corrosive sublimate, which is to be added after the decoction has been strained,—Oiss is the pro- per daily dose.) As a local application the fumigation of cinna- bar is the most efficacious, lotions being of little avail. From one to three drachms of the red sul- phuret of mercury may be sublimed and directed upon the part by a suitable apparatus. Where indurations remain after the specific treatment, an ointment formed of the ioduret of mercury (R. Hydrargyri iodid. rubr. gr. xi. Adipis §i.) rub- bed upon the part, is a remedy of great efficacy, and is much assisted by the occasional use of a douche of vapour continued for twelve or fifteen minutes. T j Todd_ [ACRODYNIA. Erythema acrodynia, E. acrodynum,- from aicpos, extremity, and oSwv, pain. A name given to an epidemic neurosis, which pre- vailed at Paris, and the neighbourhood, during the years 1828 and 1829, and in which the most con- stant and remarkable symptoms were numbness, formication, and, at times, darting pains in the hands and feet. The pain was compared by the patients to that which would be occasioned by needles or pins run into the parts. It was aug- mented by pressure ; was intense for a time; then diminished, and after a time disappeared, leaving the skin devoid of its natural feeling, and red— the cuticle separating in large flakes. Occasion- ally, the mucous membranes of the intestinal canal sympathized, as indicated by diarrhoea, vomiting, gastrodynia, &c. The only constant symptom, however, was the pain in the hands and feet. The disease was a precursor of the cholera, and not less inexplicable in its character and causation. Some died of it. It spread chiefly amongst the poorer classes, and where numbers of persons were crowded together. In the Caserne ties Onr- sines, in Paris, it attacked 560 of 700 inmates; and in that of La Courtille, in four days, 200 out of 500. No one died of it. Various remedial agents were employed ; but they appeared to be of little efficacy. The phe- nomena were met by what appeared to be the most proper agents; and in the latter periods of the epidemic, the therapeutist confined him- self to the use of the warm bath, fomentations, frictions, and emollient and narcotic cataplasms. (Dance, in Art. Acrodynie, in Diction, de Mf.de- cine, i. 515, Paris, 1832.) About the same period, the Dengue (q. v.) ap- peared in the Southern part of this country and the West Indies. It seems to have been a con- generous affection. The same may be said of the affections which have occasionally been described under the name Kriebelkrankheiten by the Ger- mans. The writer had recently under his care a case of sporadic Erythema acrodynum, which yielded to pencilling the hands and feet with the tincture of iodine, after a variety of remedies had been used in vain. Robley DUNGLISON.] ACUPUNCTURE. The passing a needle into the body is termed acupuncture. From for- getting that the word puncture has two significa- tions,—that it is used to signify both the wound and the act of making it, some have termed the operation acupuncturation. But to subjoin the syllables ation to the word puncture or acupunc- ture, is as improper as to subjoin them to the words preparation or fabrication, each of which already ends in ation and has a similar twofold meaning. An exactly parallel error would be to say manufacturation. The most obvious purpose of this operation is to allow the escape of the fluid of oedema or ana- sarca through the skin, or of the blood when su- perficially accumulated ; but, from an idea that various disorders arose from a kind of subtle and acrid vapour pent up, it was had recourse to, for the purpose of giving this vent, by the Chinese, from time immemorial. From China the practice spread to Corea and Japan, where it has for ages been very common. Ten Rhyne, (Dissert, de Arthritide, de Acu- punctura, &c, London, 1693,) a medical officer in the East India Company's service in 1679, gave the first information to Europe of a practice unknown to the Greeks, Romans, or Arabians; and states that a guard of the Emperor of Japan, appointed to conduct the English to the palace, was seized with violent pain of the abdomen and vomiting, after drinking a quantity of iced water when heated. He took wine and ginger in vain; and then, persuaded that he had wind, had re- course to acupuncture in the presence of Ten Rhyne. It appears that the Japanese are liable to a violent kind of colic called senki, which they regard as too severe to arise from morbid matter in the cavity of the intestines, and ascribe to some- thing morbid in the parietes of the abdomen, the omentum, mesentery, and substance of the intes- tines, converted by its stay in these parts into a vapour, the escape of which from its narrow pri- son, by means of acupuncture, is immediately followed by a cessation of the pain and distension. The guard laid himself upon his back, placed the ACUPUNCTURE. 55 point of a needle upon his abdomen, struck its head with a hammer once or twice to make it pass through the skin, rotated it between his fore-fin- ger and thumb till it entered to the depth of an inch, and then after thirty respirations, as it would appear, withdrew it, and pressed the punctures with his fingers to force out the imaginary vapour. He made four such punctures and was instantly relieved and got well. The needles are always made of the purest gold or silver, preferably of gold, and well tempered. Their manufacture is a distinct occupation, under- stood by few, and those few are licensed by the emperor. Some are fine, about four inches in length, with a spiral handle for the purpose of more easily rotating them : and are kept, by means of a ring or a piece of silk thread, in grooves, each capable of holding one, at either side of a ham- mer, usually made of the polished horn of the wild ox, ivory, ebony or some other hard wood, rather longer than the needle, and having a round- ish head covered, on the side which strikes, with a piece of leather and rendered heavier by a little lead within. Others are of silver only, still finer at their point, but with a short thick handle bent down upon itself; and are kept, several together, in a varnished wooden box lined with cloth : these are not struck with a hammer; but a fine copper canula, about an inch shorter than the needle, is sometimes employed to steady it, and prevent it from entering too far. The selection of the part fit for the operation, or for the application of the moxa,—the other great remedy of the Japanese, is usually confided to particular persons called Tensasi,—touchers or searchers of the parts, while those who apply the needles are styled Farittute, — needle-prickers, though occasionally the com- mon people trust to their own experience, taking care only to prick no nerve, tendon, nor conside- rable blood-vessel. The seat of the cause of the symptoms is the proper part, and delineations of the body are sold conveying this information. If the patient does not bear the needle well, it is at once withdrawn: but if he does, and the disease proves obstinate, it is introduced two, three, four, five, or six times. The more severe the affection, and the stouter the patient, the deeper must be the puncture. Ksmpfer,* a physician who accompanied a Dutch embassy to Japan, in 1691, and again in 1692, informs us that the Japanese make nine punctures, three rows of three each, at about half an inch from each other, over the liver, in cases of colic, and that he himself frequently witnessed the instantaneous cessation of the pain, as if by enchantment. The orientals do not, however, employ this operation in affections of the abdomen only. In tetanus, convulsions of all kinds, apoplexy, gout, rheumatism, swelled testicle and gonorrhoea, and in fevers both intermittent and continued, it is also celebrated among them ; enjoying credit, like all remedies of undoubted efficacy in certain dis- eases, for power which it does not possess over others. Between the frightfulness of running needles into the flesh and the high improbability of any benefit derived from such a practice, a hundred » Enpelbtrtus Ktmpfer, M. 0 History of Japan, translated from the Hijjii Dutch by Dr. Scheuchzer. Lon- don, 17-27- and seventeen years elapsed before any European practitioner made trial of it. Dujardin in his Histoire de la Chirurgie, and Vicq- on State-Medicine. " Uuy Patin relates that a midwife was executed at Paris who had murdered seve- ral infants, at the moment their head presented at the os uteri, by passing a long and very fine needle into the ! brain through the temples, the fonuuelle, or the nape of , the neck, or into the heart and its largo vessels. Alberti ! and Brendel quote similar examples. In the Cau.ies I Celebres we read the horrible story of a woman who, towards the middle of the last century, made it her busi- ness to murder all the new-born infants th.it fell into her hands by acupuncture, practised at the beginning of the j vertebral column, or in the brain, with the sole intention, | she told the judges, of peopling heaven more and more."— Fodere, Traiti de Medectne Legale, t. iv. p. i's:. sq. hour or more, is far more efficacious than several speedily withdrawn. I usually allow them to remain one or two hours; and have known them remain twenty-four hours, without any ill effect. I have usually found the operation requisite a | second time, and in one case, lumbago did not | yield till the ninth repetition. The modus operandi of acupuncture is un- known. It is neither fear nor confidence ; since those who care nothing about being acupunctured, and those who laugh at their medical attendant for proposing such a remedy, derive the same benefit, if their case is suitable, as those who are alarmed and those who submit to it with faith. Neither is it counter-irritation ; since the same benefit is experienced when not the least pain is occasioned, as when pain is felt. Galvanism, likewise, fails to explain it; because, although the needle frequently becomes oxidated and affords galvanic phenomena while in the body, these phenomena bear no proportion to the benefit, equally take place when acupuncture is practised upon a healthy person, and do not take place when needles of gold or silver are employed, which, however, are equally efficacious with a needle of steel. [We can scarcely conceive the effects to be anything more than a new nervous impression produced by the needle in the parts which it penetrates] Acupuncture has been successfully employed to remove the fluid of oedema and anasarca. In these cases, the needle does not require to be passed deeply; its point has merely to go through the cutis. As soon as this is done and the needle withdrawn, a small bead of water appears at the puncture, which augments till the fluid runs down ; and the oozing will continue for a longer or a shorter time,— generally for some hours, occasionally for a few days, and even after death, should that event take place. Any number of punctures may be made. Although the puncture is so minute, it is, in such cases, not devoid of danger, any more than scarification, if practised below the knee. The writer has frequently had recourse to it with great advantage in oedema of the scrotum and penis, frequently along the trunk, and the whole length of the superior extremity, and on the posterior part of the thigh, and never saw or heard of the least inconvenience. But several cases have been related to him, in which sloughing, and in some of which fatal sloughing, resulted from its performance below the knee, even though the needle had been passed merely through the cutis. Before these cases came to his knowledge, he had acupunctured the leg, and even the foot, in dropsy, and never but once saw any inconvenience, and that was merely a suppuration at each puncture. It should evidently, however,, never be performed below the knee except when absolutely necessary, a circumstance that hardly can happen, except in oedema not extending higher than the knee : and when we reflect that acupuncture removes an effect only, leaving the cause of the effusion untouched, and that a large number of effusions are the result of an inflamma- tory state, or of sanguineous congestion, and that, while lessening or removing these by bleeding general or local, or purging, we are employing means which have also a direct tendency to ex- cite absorption; and when we reflect upon the AGE. 57 powers of diuretics when those measures have previously been properly employed, we shall per- ceive that the cases of dropsical effusion in which acupuncture is required, are comparatively few. [Dr. Dunglison has used acupuncture with ad- vantage to drain off the fluid from the cellular mem- brane in anasarca. In such cases, larger needles are advisable. Some prefer them to be of the size of an ordinary glover's needle, and of a triangular shape,—a puncture of this kind being less likely to close. It has likewise been advised in ascites, in hydrocele, and in every form of encysted dropsy. By M. Velpeau it has been proposed to treat aneu- rism by acupuncture. In performing some experi- ments on animals, he found that arteries, punc- tured by the needle, became the seat of a coagulum, and were ultimately obliterated. In 1830, he read a paper before the Academie Royale des Sciences of Paris, proposing the operation in the cases in question, (Lond. Med. Gaz., and Amer. Journal of the Medical Sciences, Aug. 1831, p. 510). He found, in his experiments, that whenever the needle remained three days in the flesh, the trans- fixed artery was completely obliterated. M. Bonnet treated eleven cases of varicose veins by introducing pins through their cavities, and allowing them to remain there some time. Nine of these cases were cured. The same treatment was applied to hernial sacs. He passed three or four pins through the hernial envelopes close to the inguinal ring, and, in order that they might exert a certain degree of compression, as well as irritation, on the sac, he twisted the points and heads upwards, so as to give them a circular direc- tion. The inflammation usually commenced on the third or fourth day, and the pins were removed a few days afterwards. M. Bonnet treated four cases of inguinal hernia in this manner. In two, the hernia was small, and three weeks sufficed for the cure : the third was more troublesome. (Bul- let. General de Therap., and Amer. Med. Intelli- gencer, Dec. 1,1837, p. 317 ; and Archiv. Gene- ral, de Medecine, Mai, 1839.) Acupuncture has likewise been employed to remove a ganglion of considerable size on the extensor tendons of the foot. After the needle was inserted, pressure was applied, and within a week the tumour had entirely disappeared. (Mr. Vowell, Lond. Lancet, Aug. 25, 1838, p. 770.) When acupuncturation is conjoined with galva- nism or electricity, it constitutes galvano-punc- ture and electro-puncture (q. v.). See, on the whole subject of acupuncture, Dunglison's New Remedies, 4th edit., p. 53. Philad. 1843.] John Elliotson. AFFUSION. See articles Bathing and Fever. AGE. In nothing are organized beings more remarkable than in that perpetual mutation which seems to constitute the fundamental law of their condition. The whole period of their existence is characterised by a series of actions and reactions, ever varying, and yet constantly tending to defi- nite ends. The parts of which they consist undergo continued and progressive changes in their size, form, arrangement, and composition. The mate- rials which have been united together, and fashioned into the several organs, are themselves severally and successively removed and replaced by others, which are again in their turn discarded, and new ones substituted ; till, in process of time, scarcely Vol. I___8 any portion of the substance originally consti- tuting these organs, remains as a component part of their structure. This continued renovation of the materials of which the body consists, takes place in the most solid as well as in the softest textures ; and so great is the total amount of these changes, that doubts may very reasonably be entertained as to the identity of any part of the body at different epochs of its existence. A period of seven or eight years was assigned by the ancients as the time required for this entire change of all the materials of the system ; but modern researches, which show us the speedy reparation of injured parts, and the rapid renewal of the substance of bones that have been tinged by madder given to animals with their food, render it extremely pro- bable that a complete renovation may actually take place in a much shorter period. General as this law may appear, it is subordi- nate to another and more universally controlling principle, to which all beings endowed with life are subjected, namely, the Law of Mortality. Every living being has a period assigned for its existence. With the germs of life are intermixed the seeds of death ; and, however vigorous the growth of the fabric, however energetic the en- dowments of its maturity, we know that its days are numbered; and that even if it should escape destruction from causes that are accidental and extraneous, it is sooner or later doomed to perish by the slow, but unerring operation of natural and internal causes, inseparable from its nature, and coeval with its birth. In tracing the gradual succession of phenomena that mark these eventful changes, and constitute the numerous and almost insensible steps of tran- sition which connect them, a multitude of inter- esting topics of inquiry present themselves. Much instruction is afforded with regard to the physical laws of the animal economy, by the study of that condition in particular of the system, in which it has passed its meridian state of activity, and may be regarded as on the decline; and in which the causes that ultimately conduce to its destruction begin to prevail over the conservative powers that had hitherto predominated. Such is the state which is emphatically denominated Age. As youth is the state of transition from infancy to maturity, so age is the state of transition from maturity to decay. In the early periods of life, all the powers of the system are directed to the building up of the frame, and of the different organs; to their extension, consolidation, and perfection ; and to their adaptation to the perfor- mance of their several functions. The exertions made for the attainment of these objects are great, and commensurate with the magnitude and im- portance of the design; and they give rise to a rapid and varied succession of changes. An abundant store of materials is wanted for these operations; and although the consumption and renovation of these materials be considerable, yet the supply much exceeds the loss; and the body, accordingly, continues to augment in bulk. In course of time, these opposite processes of repara- tion and decay approach nearer to an equality, and, at length, are exactly balanced. The parts then cease to grow; the system has reached its state of maturity ; and the object of the vital powers and functions is now to maintain it in a 53 AGE. uniform condition of health and vigour, qualified for the exercise of all its physical and mental faculties. It cannot but excite our admiration to contemplate the accuracy of the adjustments by which these objects are so perfectly accomplished, and that equilibrium preserved, with such won- derful constancy, for so long a period of years. But at length there comes a season when the balance, hitherto so evenly kept, begins to incline ; the powers of the system are less equal to the demands made upon them; a diminution of energy becomes sensible; and the waste of the body exceeds the supply. Yet nature is far from abandoning her work : new arrangements are made, and new provisions resorted to for accom- modating the system to these changes. In pro- portion as the supply of materials for repairing the waste of the organs becomes less abundant, a more strict economy is adopted ; the resources of the system are husbanded with greater care; and the functions thus appear to go on for a con- siderable period without any material or very manifest alteration. Yet all this time the changes which are going on, though insidious, are no less real. Old age steals upon us by slow and imper- ceptible degrees, which, even when obvious to others, are often unknown to ourselves. Nature, when the system is entrusted wholly to her laws, thus kindly smooths the path along which we descend the vale of life, and conducts us by easy stages to our destined place of repose. But the number of those who thus gently glide along the stream of years is small indeed, compared with those whose declining age is withered by infirmi- ties or embittered by disease. The "Age that melts in unperceived decay" is rarely met with amidst the numerous and diversified causes of premature decrepitude, to which man, in his civilized condition, is obnoxious. Various and complicated as are the changes which the system undergoes in passing from the state of maturity to that of old age, and thence to decrepitude and dissolution ; and, different as are the objects which nature appears to have in view in the several periods of life, it is probable that a minute inquiry into all the circumstances that mark these epochs, will reveal to us the con- tinued and uniform operation of the same prin- ciples throughout the whole succession of these changes. The experience we possess of the plans and operations of Nature in other instances is altogether in favour of such a hypothesis. But in order to form a proper estimate of the degree of confidence to which it is entitled, we must examine the exact nature of the progressive changes which have been observed to take place by age in the several classes of textures and func- tions composing the animal economy. In this inquiry our first attention will naturally be directed to the mechanical properties of the several textures. The most superficial view of the subject will suffice to impress us with the great difference that exists in the relative propor- tion of fluids and solids in the earlier and in the later periods of life. The primitive condition of the embryo is, in all animals, that of a gelatinous pulp. In this pulp we trace, by degrees, the form- ation of filaments and membranes : these extend and are fashioned into organs of various kinds, which long retain their original softness of con- sistence and imperfect cohesion. The accretion of new materials imparts to them, in process of time, greater density and firmness. The propor- tion of solid matter that enters into their com- position thus continually augments; the body expands in all directions, and soon requires some mechanical basis of support. This support is provided in the osseous structures that are now superadded ; at first only partially, and in de- tached masses; but these are afterwards united into a connected framework of bone, which con-' tinues to receive developement during the whole period of the growth of the body. The softer textures are at the same time gradually consoli- dated, and acquire a higher degree of elasticity : while they, in the same proportion, become less flexible and less extensile. All the parts that are principally formed out of the cellular tissue ex- hibit these changes most remarkably. They are very perceptible in the membranes, ligaments, tendons, and cartilages ; and they may be traced even in the muscles themselves. The condensa- tion of all these parts proceeds as age advances, and is then attended with a general contraction of their dimensions. All the parts composed of fibres acquire toughness by age. This is matter of common observation with regard to animals that are used as food ; the flesh of old animals is less easily torn asunder by the teeth, and is less digestible by the stomach, than that of the same species when young. In very old animals, parts that had originally been muscular, appear, by a change of substance, to be converted into tendons; a denser material being substituted for the proper muscular fibre. The deposition of a bony material in various structures to the purposes of which it is quite foreign, and where, consequently, it appears to be misplaced, is an extreme instance of the same tendency to increased density of texture. Ossi- fication takes place, in advanced age, in various membranes, in the coats of the blood-vessels, in the coverings of the viscera, and more especially in tendons and cartilages. A similar change affects even the bones themselves ; for they be- come harder and more brittle in the progress of age. The tendency to ossification, arising from the redundance of osseous matter, is occasionally so great as to lead to the formation of osseous tumours in various parts of the body. In this respect, therefore, the bones differ from almost all the other parts of the body ; for while the latter shrink and contract in their dimensions by age, the bones, on the contrary, have a tendency rather to augment in size, or at least to increase in the quantity of solid materials which compose them. Those bones, which, in the adult, are detached, are frequently united in advanced life : such as those of the sternum and of the skull, the sutures of which are commonly obliterated, first on the inner, and lastly on the outer surface ; so that, at length, almost the whole cranium consists of a single bone. But even when not converted into bone, the fibrous structures lose their flexibility by age, and acquire a degree of rigidity which often disquali- fies them for the performance of their usual func- tions. The joints of old persons become less pliable from changes of this kind taking place in the synovial membranes and the surrounding liga- ments. The intervertebral cartilages undergo, by age, a similar process, which impairs considerably AGE. 59 the flexibility of the spinal column, and contri- butes to the bending forwards of the body and to its diminished stature. It has been observed of the fibrous tissues of old persons, that they assume a deep yellow colour, indicating the condensation of their substance, and resembling what takes place when they are artificially dried. From a tonsideration of these and other cir- cumstances, the general fact may be considered as established, that the proportion of fluids in each organ, and also in the body generally, diminishes as we advance in life. This remark applies more especially to the general mass of the blood ; but it holds good also with regard to all the other fluids : and we can scarcely doubt that a considerable proportion of those peculiarities that characterise the period of senility may be traced to the long continued operation of this principle. Together with the mechanical changes of tex- ture we have now described, we find that there also take place considerable alterations in the chemical condition of the fluids and solids of the body. In the fcetus and the infant there exists a large proportion of water and of gelatin : phos- phate of lime is but little abundant, and fibrine is but scantily developed. These two latter elements increase in quantity as the growth of the body proceeds. On the other hand, as age advances, the gelatin gradually disappears, or at least bears a much smaller proportion to the other animal constituents, namely, the albumen and the fibrin ; the aqueous portion is much diminished in quan- tity, and the phosphate of lime, as before remark- ed, often accumulates in an excessive degree. Not only is the quantity of gelatin diminished, but it appears to undergo an alteration in its quality by the effects of age. Glue obtained from young animals is found to differ essentially from that which can be procured from old animals. Calves'-feet jelly is not the same with the jelly afforded by the feet of the full-grown ox. The latter has a deeper colour, is less digestible, and passes more slowly into a state of putrefaction. A similar remark applies also to the fibrous tex- tures themselves, which become yellow by age, are less easily resolved by maceration, and resist putrefaction for a much longer time than the same parts taken from young animals. If we next examine the changes which the se- cretions undergo, we shall find that they partake of the general diminution of fluidity incident to old age. Those that consist chiefly of the watery exhalations of the blood are more scanty than in early life. The perspiration, for instance, is far less abundant. A deficiency of lymph is percep- tible in the cellular tissue; and the lymphatic vessels, having less fluid to convey, shrink in their diameter: and a large proportion of them, becoming useless, are obliterated and lost. The same takes place with regard to the lymphatic glands, which, from being large and turgid in infancy, are smaller and more compact in the adult, and either become ossified or entirely dis- appear in old age. The blood itself becomes darker coloured in advanced life. From the dimi- nution of perspiration, less animal matter is ex- creted by the skin, and more is carried off by the discharges from the mucous surfaces. We may probably ascribe to this cause the foetor which is bo often attendant on the breath of old persons. From the same cause the urine is generally higher coloured, more odorous, and more prone to calcu- lous deposition. From the mucous membranes of the nose, fauces, trachea, and lungs, there is frequently, indeed, a disposition to more copious secretion than exists in a less advanced age ; but this ought rather to be regarded as a state of chro- nic disease than as the natural condition of the parts. When it prevails, however, the mucus poured forth is opaque, viscid, and tenacious ; and its abundance proves a source of continual dis- tress to the aged valetudinarian by the obstruction it occasions to free respiration, and by the perpet- ual efforts required for its expulsion. The integuments, being the parts of the body most exposed to observation, exhibit more distinct- ly, perhaps, than any other, the changes induced by age. It is doubtful whether the cuticle, which of all the textures seems to partake the least of vitality, and which has even been considered as wholly inorganic, suffers any other alteration in process of years, than that of becoming somewhat thicker and more dry, and more disposed to peel off in scales. Compared, indeed, with its struc- ture in infancy, when it is very thin and delicate, and allows of the ready transmission of impres- sions to the subjacent nerves, the cuticle of the aged presents a striking contrast; but between the aged and the adult the differences, in these re- spects, are scarcely perceptible. The principal changes that take place during the transition be- tween these latter periods are observable in the subjacent textures. The corpus mucosum acquires by age a darker colour, as well as greater conden- sation. The cutis vera, also, exhibits greater den- sity and toughness ; while it loses in the same proportion its extensibility, and power of accom- modation to the size and figure of the parts it co- vers. The difference in the texture of the skin at different ages is very perceptible to the dissect- or -, and both the scalpel which divides the skin, and the needle employed to sew it together after division, meet with considerably greater resistance in old than in young subjects. As it no longer adapts itself to the alterations of position or of bulk which occur in the subjacent parts, it be- comes flaccid and wrinkled whenever these parts diminish by age. All this is very perceptible in the face, neck, and hands. Hence we may trace the gradual shrinking and corrugation of the fea- tures, which regularly follow the progress of years, and which afford unerring indications of age. Witness the dark coloured furrows of the cheeks and lower part of the face, the result of reiterated impressions from various passions, of which the predominating effect is to draw down the comers of the mouth, and compress the nostrils : witness the lesser lines on the temples, radiating from the eyes, and denoting the increased efforts which ac- company the employment of those organs : wit- ness, also, the deeper wrinkles in the brow and forehead, bearing the impress of intense and anx- ious thought. Grey hairs, the proverbial attendant upon age, exemplify the operation of the same principle of defective nourishment and suppressed secretion. Early and vigorous in their growth, the hairs of the head are generally the first to show symptoms of decay. Great differences may, however, be observed in different individuals, as to the period when the hair exhibits a change of colour, or falls 60 AGE. off. In some, it grows grey at thirty years of age, or even earlier ; with others, this change does not take place till other and less equivocal indications of age are manifested. Many causes which affect but little the general constitution, accelerate the death of the hair; and more especially the de- pressing passions, intense thought, and corroding anxieties. Fevers are often destructive of the vitality of the hair, when they do not permanently affect any other part of the body. There is, how- ever, an essential difference in the effects of dis- ease and of old age upon hair, inasmuch as the former seldom destroy the bulbous capsule from which the hair is formed; and, accordingly, a new crop of hair is often found to spring up, after a certain time, when the system recovers its vigour. But the death of hair from age is hopeless and irretrievable, for it implies the destruction of every part of the root, as well as the shaft; and the consequent separation of the hair is attended with the obliteration of the canal which it occupied, and which penetrated the true skin. The loss of colour in hair begins in the shaft, which first becomes grey, then white, and lastly transparent, giving to it that silvery appearance which is esteemed so venerable a mark of age. Baldness generally commences over the upper parts of the temporal and occipital bones, particu- larly in the male sex; and thence spreads over the whole upper surface of the head. The hair on other parts of the body suffers corresponding changes with those of the head, and also falls off partially by age. The alterations which take place in the eyes by the progress of age afford another instance of the tendency to a diminution in the aqueous con- stituents of the body. As the quantity of the aque- ous humour in the anterior chamber of the eye diminishes, the cornea necessarily becomes less prominent, and its curvature being thus diminish- ed, it ceases to have the same refractive power. The vision of near objects becomes indistinct; because the rays proceeding from them, and arriv- ing at the cornea with a sensible degree of diver- gence, are not sufficiently refracted to enable them to meet in a focus upon the retina : and the im- ages there formed are, consequently, confused. Such is the condition of the presbyopic eye, re- quiring the assistance of a convex lens in order to supply this deficient power of convergence. There is, however, great reason to believe that the mere change of convexity of the cornea is not the sole, nor even the principal cause of the inca- pacity of the presbyopic eye to see near objects distinctly : for this defect is more connected with the diminution in the powers of adjustment in the eye, owing to impaired muscular power. Changes also take place in the more internal parts of the eye by old age ; the crystalline lens generally acquires a yellow or amber colour; and its transparency diminishes. The sensibility of the iris is impaired; and the pupil is habitually more dilated than formerly. The pigmentum nigrum has been known to lose its colouring material, and to become almost transparent. This, as well as the larger aperture of the pupil, have been considered as special provisions of nature for admitting more light to the retina, in compen- sation for the diminished sensibility of the nerves of vision. It is probable that the various parts of the in- ternal ear are affected by the progress of age. The fluid which occupies the internal cavities is said to be gradually absorbed, so that at length it is found to have entirely disappeared. When- ever this happens, it must of course be produc- tive of irremediable deafness. But many other causes, which relate to other branches of our sub- ject, may contribute to the tendency to deafness incident to advanced life. Among the causes of the changes that take place in the internal organs, the most important is the alteration in the condition of the blood- vessels. Not only does the proportion which the blood-vessels, taken altogether, bear to the whole bulk of the body, undergo a gradual and progres- sive diminution from infancy to youth, from youth to manhood, and from manhood to old age; but a material alteration takes place, during these suc- cessive periods, in the relative disposition of the several classes of vessels among themselves. While the body is extending in growth, the arte- ries are exceedingly numerous, and pervade every part; but in proportion as that extension ap- proaches to its limit, they contract in their dia- meter, being less capable of dilatation in conse- quence of the increased density and rigidity of their coats. This contraction is chiefly percepti- ble in the smaller arteries; a number of the minu- ter vessels become impervious, and gradually dis- appear, or assume the form of ligamentous fila- ments. The sanguineous appearance which is common to so many parts in youth is altogether lost. Few red points are seen on separating the periosteum from the bones, or the dura mater from the cranium, in old subjects ; and scarcely any blood issues on making a section of these bones. In making anatomical injections, we al- ways succeed best with young subjects; in the old, we can often do no more than fill the arterial trunks, from the resistance that is opposed to the passage of the injection into the lesser branches. The coats of the arteries themselves appear desti- tute of the vessels which are proper to them, and which are so conspicuous at a less advanced age. But this obliteration of so large a proportion of minute arteries and capillary vessels, gener- ally, is accompanied with a greater comparative dilatation of the veins. The coats of the veins are originally thinner than those of the arteries; and as they do not partake of the changes which we have described as taking place in the arteries, they come to differ more and more from the latter in their texture, as age advances. Instead of thickening and contracting, it would appear, in- deed, that they became rather thinner and more dilatable than before. This perhaps arises from the coats of the veins having a smaller proportion of cellular substance interposed between them than the coats of the arteries ; they, therefore, scarcely participate in the increasing condensation of that substance, but are more under the influ- ence of the action of the absorbents. Certain it is that m extreme old age the veins are very full and prominent, and their course more tortuous : their total capacity must therefore be increased. Hence, while the total quantity of blood in the body is diminished by age, a greater proportion ot the whole mass is contained in the venous than in the arterial system. In youth this proportion was nearly equal; in age the veins contain per- haps, two-thirds of the mass of blood. ' AGE. 61 Much light has been thrown on the changes that take place in the texture of the different classes of blood-vessels by the researches of Sir Clifton Wintringham, whose experiments have clearly proved the greater proportional density of the coats of the arteries to that of the veins in old than in young animals. Hence it follows, as a necessary consequence, that they must yield more easily to the distending forces of the circulation ; and hence, whenever a plethoric state of the sys- tem occurs, that fulness will, in youth, affect more the arteries, and, in age, the veins. It is on these principles that Cullen founded his celebrated and beautiful theory of hemorrhagy, which gives so natural and satisfactory an explanation of the prevalence of arterial hemorrhagies in the earlier periods of life, and of venous hemorrhagies in the later periods. Hence, also, the greater frequency of hemorrhoids, and of sanguineous apoplexy in the old. The veins of the inferior extremities are very liable to varices in advanced life ; and they are generally more dilated than those of the arms or other parts ; for the pressure of the column of blood they have to support is a force which con- stantly operates to distend them, and which, when their strength is diminished by age, they are un- able to withstand. This proneness to varix is particularly observable in elderly women who have borne many children, from the frequent dila- tation the veins have experienced in consequence of the pressure of the gravid uterus. It is re- marked by Bichat, that, while young subjects are preferable for tracing the course of the arteries, anatomists should choose old bodies for studying that of the veins. It appears, also, that the growth of the heart does not keep pace with that of the sanguiferous system ; and we may presume, therefore, that its force does not increase in the same proportion with the increasing density and resistance of the solids. This gradual alteration in the balance of the forces of propulsion and of extension, that takes place during the growth of the body, is con- tinued in after life, and is one of the primary causes of the observed phenomena of age. The diminished energy of the heart, in these later periods, is manifested by the languor and slow- ness of the pulse, which becomes, at the same time, apparently more full ; occasionally we find it intermittent, indicating the diminished irrita- bility which pervades the system, and in which the heart at length participates. In old persons the number of pulsations in the minute often does not exceed fifty, and is sometimes even less than this. The consequences resulting from the diminish- ed energy of the circulation, and the deficiency in the circulating fluids, are sufficiently obvious, and may be traced in all the functions. Not only will less blood be sent to the several organs, but the blood that is sent, is, perhaps, less completely acted upon by the air in respiration, on account of the diminished proportion which is transmitted through the pulmonary system of vessels. The diminution of secretion, and the deterioration of the fluids prepared by the secretory organs, are direct consequences of these changes. The func- tion of digestion itself, the source of those ma- terials from which the blood is prepared and its losses replenished, and from which all the parts derive their nutriment, is less effective than for- merly. On the whole, however, the changes that take place in the secretions, and in the powers of digestion, are less considerable than those that occur in other functions. The liver and kidneys, for example, are nearly as active, and perform their respective offices as completely in age as in maturity, and while the muscular and nervous powers have sensibly declined. An exception occurs, indeed, with regard to the secretions sub- servient to generation, which, together with the generative powers, entirely cease after a certain period of life, which varies considerably in differ- ent individuals. In the male sex, after the func- tions of the testes have ceased, an absorption fre- quently commences in these glands, which shrink, become soft and pulpy, and sometimes almost wholly disappear. The prostate gland, and espe- cially the posterior lobe, is exceedingly liable to a morbid enlargement. In the female, the ovaria shrink in size, and lose their vesicular structure. The mammae, when not affected by scirrhous in- durations, are also softer, less elastic, and fre- quently pendulous ; but in advanced age they are often totally absorbed, and even the nipple is scarcely apparent. The areola generally assumes a darker colour, even prior to the period when menstruation ceases. This increased activity of the absorbent system may, on the other hand, be considered as a com- pensation to the diminished power of the sangui- ferous system. The absorbents seem to retain their powers for a longer time than the heart and arteries; and their disproportionate action is the occasion of many changes, that take place in the form and bulk of various parts. It is one prin- cipal cause of the general consolidation and in- duration of the organs. It is productive of a state of comparative emaciation, from the removal of the fat, which, in the adult, is interspersed very largely in the subcutaneous cellular texture, as well as in many other more internal parts. The effects of the loss of adipose substance are very visible in the countenance ; the eyes retreat into the sockets, the cheeks become hollow, the teeth decay, loosen, and drop out, the gums and the alveoli themselves are reduced by absorption ; all combine to alter the features, and transform their expression to that which characterizes age. The lower jaw, deprived of its teeth, advances, so that the chin projects, and comes nearer to the nose; and the cavity of the mouth being thus diminish- ed in its capacity, the tongue often appears too large to be contained in it. Amidst this general change in the configuration of the bones of the face, the nasal cavities remain undiminished in their size. At a still more advanced period, however, we frequently have occasion to observe a failure of action in the absorbents, and a consequent ten- dency to dropsical accumulations. So intimately are all the functions of the ani- mal economy linked together in one harmonious system, that a change made in any one of them must necessarily affect all the others, by disturb- ing the nice balance which is established by nature between them. Hence the difficulty that must always be felt in tracing to their origin the long and complicated series of changes that constitute any considerable alteration in the state of th« system : and when, as in the present case, the in AGE, quiry relates to alterations that are extremely I gradual, and extend over considerable periods of time, we are still less likely to arrive at any cer- tain conclusion. Thus, after prosecuting our in- duction of facts to the length of establishing cer- tain leading principles, according to which the slow progress of years affects the different organs and functions of the body, we find great difficulty in proceeding farther in their generalisation, and in reducing them to a single principle. We have seen, for example, that a great number of changes occurring in the body by the lapse of years imply the operation of a general consolidating cause, affecting both the solids and fluids, and exerted especially on the cellular and membranous tex- tures, which appear to be primarily acted upon, and through which all the parts into which the cellular texture enters as a principal component part, become also more and more condensed as age advances. The gradual diminution of the energy of circulation, and the obliteration of the minuter vessels, constitute together another gen- eral fact, which includes a large proportion of the phenomena characterizing the transitions from the earlier to the later stages of life. Now it may be proposed as a question whether these two causes, while they act conjointly, act also independently of one another; or whether the one is not an intimate and necessary consequence of the other. Is the closing of the capillary arteries, it may be asked, the effect of the tendency which the ani- mal fibre has to progressive condensation ; or is not this condensation the effect, rather than the cause, of the diminished impetus of the circulat- ing fluids incident to age ? Again, if we admit this last hypothesis to be the true one, then we have still farther to seek for the cause of this dimi- nution of force in the circulating fluids : and this brings us to another step in the investigation, namely, the inquiry into the changes which take place, in the progress of life, in the muscular and nervous powers. The muscles are found to undergo, in the course of years, changes as considerable, though perhaps not so obvious, as the other textures. They par- ticipate in the condensation incident to the cellular texture that enters so largely into their composi- tion, and which, as has already been pointed out, frequently acquire, by the deposition of fibrous or even osseous matter, the density of tendon or of bone. This excess of density in the cellular mem- brane, that invests the muscular fibres, is itself an impediment to the free contraction of those fibres, which are, therefore, from this cause, performed more slowly. But independently of this, a change also takes place in the muscular fibres themselves : they become more rigid, and the total size of the muscle is diminished. Its contractility is also im- paired ; so that it is less readily as well as less powerfully influenced by stimuli. The muscles of voluntary motion are less under the control of the will; and the involuntary muscles execute their functions with diminished energy. Not only is the irritability of the muscle im- paired, but also that property which has been denominated its tone is diminished. The texture of the muscles of elderly persons is loose, flabby, and relaxed: this flaccidity is perceived more especially in the thick muscles of the lower ex- tremities, as the glutsei, the solaei, the gastrocnemii, and biceps muscles ; while, at the same time, the individual fibres of those muscles are, in them- selves, tough and dense. A greater degree of vacillation characterizes the actions of the mus- cles of the limbs in advanced age. Hence the tottering and uncertain gait of the infirm old man. Bichat observes that this irregular action of the muscles is generally accompanied by a deteriora- tion of their substance, indicated by greater pale- ness, and the assumption of a light yellow colour, as if an approach was made to their conversion into sebaceous matter. He remarks that this change is more commonly observed to take place in the deep-seated muscles of the back, which occupy the longitudinal spaces between the pro- cesses of the vertebrae ; and that it does not affect the muscular system generally, but only a small number of isolated muscles. (Bichat. Anatomie Generate, torn. iii. p. 336.) The same phenome- non has been noticed in muscles that had long been affected with paralysis. The prevailing diminution of muscular strength is manifested, very unequivocally, in the affection of the voice, which, in old age, becomes shrill and tremulous; and the " Big manly voice, Turning again towards childish treble, pipes And whistles in his sound." A diminution of tone is also exhibited in the muscular coats of the alimentary canal; the stomach and intestines are habitually more di- lated ; that is, they do not so readily contract upon their contents, when but little is contained in them. The same is the case with the bladder, which remains large, even when void of urine. The diminution of power in the muscular fibres of the bladder is productive of a double evil; as it is rendered less capable of retaining the urine when distended, and also less capable of com- pletely emptying itself. Together with this want of power, the bladder often gets irritable in advanced life : and to this increased irrita- bility the enlargement of the prostate often con- tributes, by impeding the action of the sphincter, and lessening the diameter of the canal of the urethra. But muscular contractility is itself intimately connected with the condition of the nervous sys- tem ; and before we can form a proper estimate of the causes that occasion the decline of the muscular powers, we must take into consideration those that affect, in corresponding periods, the nervous powers. The structure and composition of the brain undergo, by the progress of age, changes no less great and important than those that affect other parts. The substance of this organ, at the time of birth, is almost fluid ; so that, when taken out of the cranium, it has hardly sufficient consistence to retain its figure. As the body grows, it acquires greater consistence and firmness ; in the same pro- portion, we may observe that a smaller quantity of blood circulates in its vessels. In the progress of life this condensation still proceeds, and the subdivisions of that organ are more distinctly marked ; hence, in advanced age, the brain be- comes better adapted for tl'e anatomical study of its minuter parts. The distinction of colour be- tween its medullary and cortical portions is more strongly marked, and is particularly visible in the optic thalami, the corpora striata, the cornua am- monis, and in that portion of the lower part of AGE. 63 the third ventricle which gives origin to the peduncle of the pituitary gland. An alteration also takes place in the chemical properties of the substance of the brain ; Bichat remarks that chemical re-agents act more slowly upon the brain of the adult than upon that of an infant. This is more particularly the case with the dissolving power of alkalis, which is much less in the former than in the latter. The blood-vessels and membranes of the brain become more tough and rigid, and are often incrusted with osseous deposits. The dura mater is easily detached from the inner surface of the skull, in consequence of the obliteration of most of the vessels that estab- lished a connexion between them. It is only at the sutures that it remains attached : and even there the connexion becomes less firm as the su- tures become themselves obliterated by the progress of ossification. The pia mater and tunica arach- noides acquire greater thickness ; and the former presents a redder appearance than formerly ; a circumstance which offers a marked contrast with the diminished quantity of blood in the sinuses and neighbouring parts. In general the whole mass of brain is diminished in size in advanced age, so that it does not completely fill the cavity of the cranium. Sometimes, indeed, a contrary change to that above described is observed to take place, the brain of very aged persons being found in a softer and more flaccid state than in the adult; but this should be considered rather as a diseased state than the natural effect of age. The nerves undergo changes from age very analogous to those of the brain ; though, perhaps, less distinguishable, in consequence of the mem- branous covering with which each of their fila- ments is invested. The proportion of nervous matter appears to be diminished ; as is certainly the case with the number and size of their blood- vessels. The ganglions connected with the nerves become harder, and of a deeper grey colour, and shrink considerably in their size. The functions of the several parts of the nervous system are, doubtless, dependent on their organi- zation ; but no knowledge we have been able to obtain of the nature of that organization from ana- tomical inquiry, or from any other mode of inves- tigation, has thrown any light whatever on the mode in which these functions are conducted. We cannot, therefore, predict, except in the most general way, what modifications of function will result from any observed alteration of structure in this system. All the knowledge we can attain on this subject must be that derived from direct obser- vation, and from induction of the facts so obtained. Now, the whole series of phenomena that charac- terize the decline of life, indicate the gradual dimi- nution of the energy of the nervous system in general, and of the brain more especially. All the sensitive functions are performed less perfectly. The organs of the external senses become less capable of receiving impressions from their respec- tive objects ; the nerves transmit more tardily and more feebly these impressions to the brain; and the perceptions to which the transmitted impres- sions give rise are less vivid and more transitory than formerly. The sensibility of the system generally is di- minished by age. Bodily sufferings, from the same causes, are less acute ; and equal injuries excite less constitutional disturbance ; inflamma- tion is more languid. Painful affections, such as cancer, are felt less acutely in age than in the meridian of life, and these, as well as all other diseases, have a disposition to assume a more chronic character. The system is less susceptible of the action of contagions of all kinds; and if, by a certain age, it has not gone through the usual course of exanthemata, and other diseases which affect the body only once in the course of life, it generally escapes them altogether. The temperature of the body is probably lower in age than in youth. An explanation of this fact has been sought for in the diminution of the quantity of fat, which, by its non-conducting pro- perties, prevents the escape of heat from the body: but it seems more reasonable to account for it by the decline of the powers both of the circulation and of the nervous energy in general. Whatever be the cause, chilliness is a very common attend- ant on old age. It might, perhaps, be concluded, from reasoning a priori on the facts already stated, that the more easy exhaustion of the sensitive powers would call for a greater proportion of sleep, in order to restore and maintain them. Yet we find, in reality, that old persons sleep less than those that are young, and that their sleep is much less profound, and oftener disturbed by dreams. Pro- bably, the explanation may be found in that law of the economy which appears to regulate the quantity of sleep by the necessity that exists for nutrition. Thus, when the body is growing, as in young children, sixteen hours out of the four-and- twenty are passed in sleep. Adults sleep, on an average, seven or eight hours ; but for the aged, five or six hours are generally sufficient. Many exceptions, indeed, occur to this, as well as to every other rule in which the operations of the nervous system are concerned ; and especially in those depending so much upon habit, which is justly esteemed a second nature. Persons of great age sometimes experience very distressing wake- fulness ; this is often the effect of cold feet, indi- gestion, or other internal sources of irritation. The mind, as well as the body, is wasted by time. The first indication of diminished vigour in the intellectual faculties is usually the decay of the memory. The power of recollection, which is immediately dependent upon that of association, appears to have a closer relation to the physical condition of the sensorium, than any other of the mental faculties : for we often observe a failure of memory, while the judgment continues unim- paired. This loss of power is chiefly felt in the case of new associations. Thus recent events are recalled with much greater difficulty than old ones; and new habits can hardly ever be contracted. The earliest notice that is given of this partial decline of the faculties is generally in the forget- fulness of the names of persons. When carried somewhat farther, the names of things are with difficulty recollected. The mind loses that com- mand of language which it formerly possessed ; hence the tardiness of speech, and heaviness of expression which characterize the conversation of so many persons of advanced age. The garrulity of old persons is also frequently a consequence of the deficiency of memory, which effaces the recol- lection of what has just been said, and leads to continual reiteration of the same ideas. Not only are the bodily feelings impaired by age ; the mental sensibility is also blunted, in at 64 AGE. least an equal degree, in all that relates to present or recent impressions. Yet it has often been remarked that old persons feel acutely the loss of former friends and companions. How often do we not witness the survivor of an aged couple soon follow his partner to the tomb ! The failure of the sight, of the hearing, the senses which con- nect us most largely with the external world, con- tribute much to the diminished exercise of the intellect, by abstracting the occasions for exertion; and we well know that, without exercise, the intel- lectual as well as the bodily powers stagnate and become torpid. To this cause are often added impediments to bodily exertion arising from rigidity of the membranes, stiffness of the joints, debility of muscles, and impaired nervous energy. The tottering steps and tardy movements of the infirm old man can be accompanied with none of the enjoyment which attends the exertions of limbs animated by the elastic spring of youth. If, under these circumstances, he should unfortunately be deprived of the resources of mental cultivation, can we wonder that he is driven for refuge to the enjoyment of those senses of taste and smell that yet remain ; and that he devotes himself to the cultivation of the pleasures of the table, and the artificial excitation of spirituous liquors ? Y^et even here nature imposes certain limits, beyond which the votaries of luxury are forbidden to pass. " Time hovers o'er, impatient to destroy, And closes all the avenues of joy. In vain their gifts the bounteous seasons pour, The fruit autumnal, and the vernal shower; With listless eyes the dotard views the store, He views, and wonders that they please no more. Now pall the tasteless meats and joyless wines, And luxury with sighs her slave resigns." Need we pursue this " strange eventful history" to the last melancholy chapter of man's existence, and contemplate the wreck of those exalted facul- ties which ennoble his nature, and of which the deprivation lowers his condition far beneath that of the beasts of the field ? Need we dwell upon the sickening spectacle of " second childishness and mere oblivion ;" and disclose those mournful contrarieties of our nature, that drew forth the exclamation from the poet — " In life's last scene what prodigies surprise ? Tears of the brave and follies of the wise. Prom Marlborough's eyes the streams of dotage flow, And Swift expires a driveller and a show." Let us rather draw a veil on this humiliating picture of the frailties incident to humanity, and which forcibly remind us of what " We shun to know, That life protracted, is protracted woe." To revert, then, to the philosophical question which has already occupied our attention, let us inquire whether it is possible, throughout the mul- tifarious changes we have described as character- izing the several stages of the transition from infancy to decrepitude, to discover the uniform and progressive operation of any single principle. Admitting that the increasing density of the cel- lular substance is the natural consequenee of the diminished force of circulation, aided, perhaps, by the increased, or, at least, undiminished power of absorption, may we not advance a step farther, and ascribe the diminution of the force of circula- tion to the gradual loss of muscular power arising from a decline in the energies of the nervous sys- tem > If this be a legitimate inference, then this declension of nervous power, which takes place with more or less rapidity as we advance in life» appears to be the general principle we were in quest of; that is, the ultimate fact to which all others are subordinate. Appearances, then, war- rant the hypothesis that a certain stock of vital force is imparted to the embryo at its first forma- tion. as a provision for carrying it through its destined career of existence. In every action of the system a portion of this power is expended ; and the greater the expenditure, the less must there be remaining, till, at length, the whole being consumed, all movements cease, like those of a watch which has run down, and of which the main spring has ceased to act. That considerable differences exist in the stock of vitality originally imparted to the frame in different individuals, cannot be doubted ; some being destined to a shorter, and others to a longer, term of existence, independently of all adventitious causes that may occur to disturb the regular course of nature in the demolition of the fabric, and the termination of life ; while others, born with more feeble stamina, yet highly excitable, anticipate the natural epochs and stages of life, and, precocious in their youth, are doomed to premature senility and decay. Such is usually the condition of dwarfs, who generally die at an early period, bearing all the ordinary marks of extreme old age. From all that has been said we may draw the conclusion, that the spontaneous decay of the body, and decline of its powers invariably attend- ing the lapse of years, arise altogether from causes that are internal, and interwoven with the very conditions and laws of its existence, and are but little influenced by external circumstances. With inorganic bodies precisely the reverse takes place; they owe to external causes their decomposition and destruction. But living bodies perish from within, being consumed by the very fire which is itself the source of their animation. If health be viewed as consisting in the proper balance and harmony of all the functions of life, it is evident that this condition may exist in all ages, and that it is compatible with different de- grees of energy in the exercise of those functions. Though the powers of the constitution may be enfeebled by age, and though the actions may be less vigorously performed, yet if they be duly pro- portioned to one another, the system must be con- sidered as in a healthy condition, and as fulfilling the designs of nature in the latter stages of its existence. In one respect, however, there is a material difference between the health of youth and the health of age ; inasmuch as the former is more secure and stable than the latter. In the period of youth, it is true, the greater activity of the functions often endangers the equilibrium of the system ; but then the power of restoration is at the same time proportionably more efficient. Rich in its resources, the constitution of youth rebounds with surprising elasticity from the de- pression of a severe illness, and even seems to gather fresh vigour from the shock. In advanced life, on the contrary, this resilient power is defi- cient : the fibres that have been stretched beyond the proper limits no longer return to their former state; the spring no longer rc-acts with a force equal to that by which it is extended ; and a dis- placement of its particles is productive of a per- manent alteration in structure, and of augmented incapacity to perform the same extent of action. AGE. 65 The slighter deviations from the perfectly heal- thy structure of the organs, which are the con- comitants of age, are of various kinds, and their effects may be for a long time insensible. Gradu- ally, however, they increase in extent, until they manifest themselves by some outward indications of disordered health ; obscure, perhaps, at first, and apparently evanescent; yet, recurring at un- certain intervals, and acquiring, by degrees, a more decided and permanent character, they at length attract attention ; and proper means being resorted to for the correction of the derangement in the functions, the health appears to be again restored. Still, however, there is left a greater proneness to disorder than before. Various excitements and exertions which formerly were harmless are not so well borne. Slighter causes of disturbance are followed by some particular symptom or sets of symptoms to which there may exist a predisposi- tion in the system ; such as head-ach, lassitude, dyspepsia, depression of spirits, palpitation, watch- fulness, &c. It seems as if something were go- ing wrong, and preparing more serious illness. Such is generally the progress of structural dis- eases, which steal on by slow and insidious grada- tions, producing for a certain interval that unde- finable state of impending disorder, which only a very attentive and scrutinizing observation can detect, but which exists long before that eventful period commonly characterized as the breaking up of the constitution, or that in which positive disease has commenced its hostile incursions. Then, indeed, all that our most skilfully-directed efforts can accomplish is to repulse the immediate aggression, and obtain a truce from that enemy which is sure to renew the attack, and to whose power the citadel we defend must at last be un- conditionally surrendered. It has been observed that, independently of any positive alteration in the structure of a particular organ, there occasionally occurs, at a certain period of life, a sudden and general alteration of health, which is of uncertain duration, though generally of no long continuance, and to which the term climacteric disease has been applied. This pecu- liar condition has been well described by Sir Hen- ry Halford in an essay published in the Medical Transactions of the College of Physicians, (Vol. iv. p. 316.) This disease, he observes, is better characterized in men than in women ; but even in the former the period of its invasion is by no means constant, for it may occur at any time be- tween the ages of fifty and seventy-five. Its com- mencement is often apparently determined by some occasion of feverish excitement, such as an act of intemperance, a fall which seemed at the mo- ment to be of no consequence, or even a common cold. Sometimes it follows upon a marriage con- tracted late in life. But the most frequent pre- disposing cause is mental anxiety and suffering, the corroding influence of which will eventually sap the foundations of the most robust constitu- tion. The climacteric disease is described, by Sir Hen- ry Halford, as being marked by an extraordinary alteration in the expression of the countenance, by an accelerated pulse, and by a wasting of the \ flesh, without any obvious source of exhaustion. Wandering pains are felt in the head and chest; j the tongue is white, the bowels are sluggish, the j Vol. I. —9 r* nights passed either without sleep, or without the refreshment which sleep should bring with it, and there is a general feeling of lassitude and of fever. There is no deficiency of urine ; yet the legs often swell. These symptoms may be of some dura- tion ; and may, indeed, proceed so far as to under- mine the health to such a degree, that the patient sinks under a disease which seems to have no other characteristic than that of a general failure of the functions. But when, as is most frequently the case, the powers of the system are adequate to recovery, the symptoms are gradually mitigated and disappear. Then is there a return of com- parative health and strength, which may last for many years. But we may yet always remark that the energies of the frame have been permanently impaired; and the impression made upon the countenance remains fixed and indelible. Such is the climacteric disease in its simple form, as it occurs in individuals who have enjoy- ed previous health. But when it supervenes upon a frame already deranged by habitual illness, it often assumes the feature and partakes of the cha- racter of the predominant complaint. When thus associated with the effects of structural disorder, it is always difficult to assign the share that be- longs to each specific source of disease ; but the existence of the climacteric affection may some- times be inferred from the peculiar expression of the countenance already mentioned, from the unu- sual exasperation of the symptoms appertaining to the organic disease, and from its proceeding with greater rapidity to a fatal termination. It is owing to this frequent complication of previous local and constitutional ailments with the evils which are the natural consequences of old age, that the picture above drawn is not often realized in actual observation. We shall now proceed to point out the more specific diseases to which old age is most obnox- ious, and by which life, at that period, is most frequently terminated. Among the numerous indications of a wavering in the equilibrium of the functions incident to the decline of life, perhaps the most important are the symptoms of disorder in the digestive processes. Dyspepsia, in all its varieties, is among the earli- est as well as most common of the diseases of advanced life ; and its prevalence at this period may be traced to many causes, of which the ope- ration is sufficiently obvious. The principal of these is, undoubtedly, the gradual decline of irri- tability and of muscular power which pervades the whole system, and in which the fibres of the stomach and intestines must of course participate. It often happens, that while the powers of assimi- lation have diminished, the appetite still continues good ; and, consequently, more food is taken than can be converted into healthy nutriment. That portion which is imperfectly digested being retain- ed, tends, by its presence and accumulation, still further to impede the due performance of this function. The distension of the stomach and bowels from flatus, and their continued irritation from containing acid or acrid materials, lay the foundation of a vitiated habit, and of permanent injury to the tone of the organs. Another cause of imperfect digestion may be pointed out in the loss of the teeth, and the consequent defective mastication of the food. The mischief is often aggravated by the sudden discontinuance of the 66 AGE. salutary exercise which was formerly taken ; and by an indulgence in the repose which, after a life of exertion, is almost claimed as the privilege of age. Increasing sluggishness takes place in the peri- staltic action of the bowels, more especially if exercise be neglected. Hence arises a habit of costiveness, and hence are formed accumulations in the large intestines, and more particularly in the cells and flexures of the colon, which acquire a preternatural size from habitual and inordinate distension. In this way the foundation is often laid for structural diseases, which affect the coats, and lead to fatal strictures of the great intestine. Another and more frequent attendant upon ha- bitual constipation are hemorrhoidal tumours, often productive of much suffering, or profuse and dan- gerous losses of blood ; and leading, not unfre- quently, to fistulous abscesses, which terminate in a lingering and fatal hectic. Protracted dyspepsia may give rise to hepatic disease in all its various forms. The cause by which these affections are most commonly deter- mined, is the abuse of spirituous liquors. If the habit of indulgence in this Promethean poison has been already contracted, it is almost certain to increase during age, when the cravings of this artificial appetite never fail to become more inex- orable, and when the power of self-control, toge- ther with the other energies of the mind, is gene- rally diminished. Yet, provided a foundation has not been laid for diseases of the liver at former periods of life, either from the cause just men- tioned, or from the influence of a hot climate, it does not appear that there exists any particular proneness to this class of diseases in advanced life. The structural diseases of the liver, like those of other organs, are mostly of a chronic character, stealing on by slow degrees ; advancing to a cer- tain point with comparative rapidity ; then appear- ing for a long interval to be stationary : after which they proceed another step, and again stop. As a considerable portion of life may be spent while they are thus passing through their succes- sive steps of aggravation, it is natural to expect that their last and more fatal stage should occur during the later periods of life, and thus appear as the natural attendants upon old age. One cause, however, may be assigned for the more aggravated symptoms, and more rapid course of structural diseases in advanced life; and that is, the greater proneness to chronic inflammation at that period, which may itself be traced to a defi- ciency of that conservative power which main- tains the healthy balance of the circulation. This more diffused and insidious kind of inflammatory action is particularly apt to affect the serous mem- branes. Hence the aged are particularly liable to (hose dropsical affections which are the natural consequences of their inflammatory states. The same general principle will account for the ravages of cancer being more observahle in the aged than in others. We find accordingly that a large pro- portion of elderly females arc destroyed by cancer of the uterus or mamma ; while, in the male sex, the structural disease which more especially mani- fests itself in advanced life is the enlargement and scirrhous induration of the prostate gland, and especially of its posterior lobe. This latter dis- ease, besides being productive of various local inconveniences, such as irritation of the bladder, t and painful obstructions of urine, frequently preys upon the general health, and tends to exhaust the I constitution. The failure of the urinary functions is also among the more frequent causes of distress in old persons of the male sex. The first indication of a tendency to gravel is the deposition of uric acid in the form of crystals, like red sand, in the urine. i By degrees concretions are formed in the pelvis of the kidney, giving rise to acute pain, and other nephritic symptoms arising from inflammation and | abscesses in the kidneys. When these concre- j tions descend into the bladder, the well-known ! symptoms of vesical calculus are excited, which need not be enumerated in this place. But inde- pendently of calculus, the muscular power of the bladder is liable to be much impaired in advanced life, in a greater proportion than other muscular parts. Two evils, apparently of an opposite kind, yet both referable to impaired action of some of the fibres of the bladder, occur as sources of great inconvenience and distress. The one is retention of urine, from debility of those muscular fibres by which it is expelled ; and the other is the in- continence of the bladder, arising from paralysis of its sphincter. The first indication of a failure in the muscular powers of the bladder is the inability to empty itself wholly ; some urine always remaining be- hind, after every attempt at expulsion. If from some accidental circumstance the urine has been suffered to accumulate in too great a quantity, its expulsion becomes still more difficult, and may even be found to be impossible, without the intro- duction of the catheter. After the bladder has thus been stretched to an excessive degree, its tone is much impaired, and is with difficulty recovered; and even if the power of retention, to a certain extent, is obtained, this power may be accompa- nied by incontinence when that quantity is ex- ceeded, the urine continuing to come away invol- untarily, while there is still a considerable quantity retained in the bladder. Gout, though it be not exclusively a disease of age, should be ranked among those to which there is a greater predisposition in the decline of life. Chronic rheumatism, and especially that form of it which has been termed nodosity of the joints,' j is more prevalent in aged persons than in others. The or^an which participates most largely in the changes induced by age, and which also sym- pathizes most extensively with the stomach, is the brain ; and the diseases of this organ probably con- stitute, on the whole, the principal source of fatality at the advanced period of which we are treating. The failure of energy in its functions frequently shows itself in the alteration which takes place in the state of mind; in the predominance of more gloomy views of things, in habitual despondency, in increasing listlessness and lethargy, in confu- sion of thought or loss of memory, in heaviness and somnolency. Old persons are subject to noisM in the ears, to occasional head-ach, and giddiness. Partial debility is manifest in some particular or- gan of sense or motion ;' the sight or hearing fails; a feeling of numbness, or tingling, is perceived in the extremities ; wandering pains are complained of in different parts of the trunk or limbs, which are ascribed to rheumatism, but which are found to follow more the course of the nerves than of AIR, (CHANGE OF) 6*7 the muscles, and are sometimes referred to the centre of the bones. Sudden and unexpected relief is often experienced from these symptoms by the discharge of flatus from the stomach or intestines. All these are but preludes to an attack of a more serious character. Palsy or apoplexy sud- denly supervenes, and either at once carries off the patient, or, if for a time recovered from, leaves him but the wreck of his former self. It has been computed that about one-fourth of all those per- sons who attain the age of seventy are destined to perish by this disease. It would appear, from a computation made by Dr. Heberden, that apo- plexy and palsy have prevailed to a greater extent in modern times than formerly ; for the number of fatal cases from these diseases, recorded in the Bills of Mortality, is now double of what it was at the beginning of the last century. This is not the place to enlarge upon the causes, both remote and proximate, of that class of dis- eases ; it will be sufficient to observe that they appear connected with a local plethoric state of the vessels of the head, and more especially of those belonging to the venous system, in conjunc- tion with the declension of the nervous power. In a large proportion of cases they are accompa- nied with perceptible structural changes either in the cerebral substance, or in the vessels that sup- ply it. Ossific depositions in the coats of the arteries of the brain are among the most frequent of these changes. Various lesser degrees of impaired sensibility and muscular energy, occasionally perceptible in different organs, and constituting what is called partial paralysis, are referable to the same causes. Instances occur, in the relaxation of the upper eye-lid, which, in consequence, hangs over the globe of the eye; in the dropping of the under- lip, which becomes pendulous, and is no longer able to retain the saliva; in the faltering speech and tremulous voice, and in the relaxation of the sphincter, already noticed. Cutaneous disorders frequently make their ap- pearance during the decline of life. They would seem in general to be more closely connected with the condition of the brain and nervous system, than with the state of the digestive organs. Of these the most distressing and intractable is the prurigo senilis, which, though unattended with any visible eruption, is often remarkably invete- rate, and is the source of incessant and indescri- bable torment to the individual whom it affects. The heart is frequently found to be diseased in elderly persons ; hence arises another train of dis- eases, which will be described in their proper place. It will be sufficient here to indicate ossification of the coronary vessels, or of the valves of the heart; increased size of its ventricles or auricles, and dilatation of their cavities; aneurisms or ossifica- tion of the coats of the large vessels connected with the heart. Collections of water in the peri- cardium, the frequent effect of these organic changes, contribute still further to complicate the symptoms and augment the danger to life. All these occasion more or less impediment to the action of the heart; and the consequent disturb- ance of the circulation shows itself in various ways. Inflammation in the skin, particularly in the extremities, is exceedingly apt to terminate in mortification during old age. The toes arc fre- quently the seat of this affection. Carbuncle may also be enumerated among the disear.es to which there is a more particular disposition in the ad- vanced than in early or middle periods of life. The last class of diseases affecting aged per- sons, which we shall notice in this brief review, are those of the respiratory organs. The relaxed condition of the mucous membrane of the bron- chi, and the predisposition to a chronic form of inflammation, lay the foundation for those pro- tracted forms of catarrh, of asthma, and of peri- pneumony, which prevail so extensively in persons of advanced age. In catarrhus senilis, as it is emphatically called, the great abundance of the secretion from the membrane both of the lungs and nasal cavities, and its peculiar viscidity, which demands great efforts for its removal, is the source not only of great distress, but also of great ex- haustion of strength ; the constitution is frequent- ly unable to withstand the repeated aggravations of this complaint, which take place in successive winters. Under these circumstances, especially the supervention of peripneumonia notha is ra- pidly destructive of life. The occurrence of that species of epidemic catarrh, at times so widely prevalent, and which is known by the name of influenza, is always extensively fatal to very elder- ly persons : indeed, all inflammatory complaints affecting the chest are incomparably more danger- ous at this period of life. Asthma, which must certainly be enumerated amongst the diseases of age, is not, at first, or in itself, attended with the same risk ; though, in its consequences, it eventu- ally contributes to the abridgement of those years during which the life of a person of healthy lungs would otherwise have been prolonged. k"~ P. M. Roget. AIR, (CHANGE OF.) Change of air is a popular, and when well directed, very powerful remedy, in a numerous class of chronic ailments; in some acute diseases ; and in a state of conva- lescence from disease generally. Its influence also is, perhaps, still more remarkable in removing that condition of the system which may be termed rather a deterioration of health than a formal dis- ease, and which is occasioned by confinement a \\ sedentary habits, or residence in impure air; a complaint which has been termed Cachexia Lon- dinensis, although by no means peculiar to the metropolis. The striking improvement produced in the health by a removal, or a few weeks only, from the tainted atmosphere of a city to the pure and invigorating air of the country, is the subject of daily observation. Even a change from one part of the country to another is often attended with remarkable benefit, and that when there is little or no apparent difference between the two situa- tions. We use the term pure and impure in this place, because unquestionably the atmosphere in various situations differs materially in its purity, accord- ing to the ordinary meaning of the term. It may be true that the air collected in the most confined alleys of London, when subjected to analysis by the chemist, shall afford the same proportion of oxygen and azote as that to be found on the sum- mits of our highest mountains; but we have no reason to believe that oxygen and azote constitute 68 AIR, (CHANGE OF) the whole ingredients of the atmosphere. The present state of our chemical knowledge may not, indeed, enable us to determine what is the pre- cise nature of the other ingredients, but we are not the less sure of their existence, and that they often exert a pernicious influence on health. The attempts of chemical philosophers to ascertain the nature of the agents now referred to, which con- taminate the air in different situations, and speed- ily produce specific diseases, or more slowly un- dermine the health, have hitherto proved most unsuccessful. Even our means of measuring some of the obvious physical qualities of the at- mosphere are still very imperfect; so that in treat- ing of them we are often obliged to employ the terms in common use, instead of the more accu- rate and definite language of science. [Even the change from a better to a worse air has been found serviceable. In Edinburgh, the inhabitants of the most airy parts of the New Town have frequently sent their children, when labour- ing under hooping cough, to the Cowgate — a filthy street, which runs at right angles under one of the largest thoroughfares in the Old Town, and in which, at a certain hour in the night, the inhabitants eject all the offensive accumulations from their houses, to be washed away by the water of the reservoirs let on for the purpose.] Although change, of air implies some change of climate, in the extended acceptation of this term, yet by the former expression is commonly meant a removal from one place to another in the same country or climate. And it is in this more limited sense that we use the expression change of air on the present occasion. In another arti- cle, the medical effects of different climates, and of change of climate, will be fully discussed. (See Climate.) In the present article we shall con- fine ourselves to a few practical remarks on the principal circumstances which should guide the practitioner in prescribing change of air, in order that the patient may derive all the benefit from that remedy which his case admits of. It is upon the just adaptation of the remedy to the individ- ual case that all the advantages to be expected from change of air depend. In designating the predominating qualities of the air in different places, which give to them sev- erally a peculiar character, in reference to their effect on the human body, we shall employ terms in common use, as their import is well understood, and they are sufficiently explicit for our present purpose. The epithets soft and mild, as opposed to sharp and harsh ; moist or damp, as opposed to dry ; heavy or oppressive, as distinguished from light and elastic, are expressions in general use ; and the effects of the conditions of the atmo- sphere which they indicate, in soothing or excit- ing, in depressing and relaxing, or in exhilarating and bracing, are well known by experience. The different states of the atmosphere just noticed, exert a more powerful influence in proportion as the constitution is delicate; and, accordingly, change of air becomes a much more important remedy in the diseases of such persons. It is, indeed, chiefly from observing the manner in which invalids and delicate persons are affected by the atmosphere of different situations, that we are enabled to estimate its less powerful influence un the more robust constitution. Habit, and the conservative powers inheient in the human system, enable man to resist, to a cer- tain extent, the action of the deleterious qualities of the atmosphere ; yet no person, however strong may be his constitution, will long remain altoge- ther uninfluenced by them. Their effects are, m general, observable on the organization of the inhabitants of such places, and in the manner in which the various functions of life are performed in a state of health ; and they are, perhaps, still more remarkable in the nature and character of the diseases to which such persons are most ob- noxious. Although these circumstances are more strikingly observed in the natives of different cli- mates, they are sufficiently evident in the inhabit- ants of different districts in our island. In proof of this, we need only compare, in the state of health, the firmly-knit frame, the florid counte- nance, and the elastic motions of the mountaineer, with the sallow complexion and languid gait of the inhabitant of the humid plain, or confined valley. The contrast is equally strong when these individuals are suffering from disease. In the former, we have acute, febrile, and inflammatory affections ; in the latter, diseases of slower progress, with comparatively little excitement of the vascu- lar system, but with great sensibility of the nervous system. Were any proof necessary that this dif- ference depended on the locality, we find it in the fact that persons, in removing from one district to another, gradually assume the characteristics, both of health and disease, of the inhabitants of the new locality. For example, the character of the same disease attacking the Welsh mountaineer on his own hills, will be very different from that which he would be subject to after a residence of some time on the southern shores of Devonshire or Corn- wall. The physician in the metropolis, who has constant opportunities of seeing patients from all parts of the country, cannot fail to remark how much the character of their constitutions and the nature of their diseases vary according to their place of residence. It is unnecessary to point out the important practical bearing of this observation, which so happily illustrates the well-known re- mark of Baglivi, « differre pro natura locorum genera medicinac." But our attention, for the present, must be limited to the consideration of the effects of change of air in remedying disease and improving the general health. The leading circumstances which require con- sideration in prescribing change of air, are the nature of the disease, the constitution of our patient, and the quality of air best suited to these. Before noticing these, however, it may be well to make a few remarks on the periods of disease at which change of air can be employed with any prospect of benefit, or even without disadvantage. In acute, febrile, or inflammatory diseases, it is, of course, during the stage of convalescence only that change of air is proper : but when the con- valescence is sufficiently advanced to admit of a removal, and the season of the year is favourable for such passive exercise in the open air as a con- valescent can bear, a case will rarely occur in which the return of perfect health may not be materially promoted by such a measure. When the patient resides in a crowded city, or other confined situation, the change is more urgently called for; and, indeed, we feel convinced that, under such circumstances, many cases 0f severe disease occur, after which complete restoration o» AIR, (CHANGE OF) 69 health is never effected without a change of air. The person deprived of the benefit of such a mea- sure attains only to a degree of health inferior to that which he enjoyed before the occurrence of his disease ; and the remainder of his life is often little better than a state of improved convalescence. In those acute diseases which are accompanied with little fever, change of air need not be delayed till the patient is convalescent. When the more active period of the disease has passed over, and the danger of creating inflammation is greatly diminished, and more especially when the disease threatens to pass into the chronic form, a judicious change of air will often assist powerfully in putting an end to it. As examples of such diseases, we may mention the subacute forms of bronchitis, catarrhal affections generally, and hooping-cough in particular. But even in these cases the change requires to be well-timed : if too early, it will scarcely f.iil to aggravate the disease ; if deferred too long, the disease may have fixed itself in a chronic form, and the measure, consequently, prove much less beneficial than if it had been adopted at an earlier period. It is impossible, however, to do more at present than to call atten- tion to the circumstance ; the medical attendant can alone decide upon the proper period of removal in each individual case. In no class of diseases is change of air so ob- viously and imperatively called for as those which originate in the pernicious qualities of the air of certain localities, commonly, of late years, desig- nated by the general term malaria. The most conspicuous of this class is the numerous family of aguish disorders. In these cases the single measure of change of air is often sufficient of itself to remove the disease ; and the more promptly the change is made, the more effectual it is likely to prove. This measure, however, should never be trusted to exclusively in intermittent fever. The disease has been produced by a specific cause, and generally requires a specific remedy for its com- plete cure. If this be neglected, we shall frequently find that the disease has only been suspended, not cured. The period when the paroxysms are sus- pended by the removal of the patient from the source of his disease, is the most favourable for employing the proper remedies for securing him against a relapse. Even when the removal does not suspend the disease, it renders it more amen- able to the action of medicine ; and, were it only with this view, change of air should be adopted in such cases whenever it is practicable. The per- fect re-establishment of health is scarcely ever effected in the severer forms of those diseases, as far as our observation goes, without a complete change of residence for a considerable time. The indiscriminate manner in which change of air is recommended, with little regard to the con- stitution of the patient, the nature of his disease, or of the place whither he is sent, are the principal reasons why this measure so often disappoints the hopes of the invalid and his friends. It is quite essential to success that the air of the place selected should be suited to the patient. The feeble and irritable invalid will not bear a keen exciting air, whatever may be his disease; whereas the invalid possessing a constitution of an opposite character will feel increased vigour while breathing such an atmosphere. As an example of this difference of result in the same disease, we may refer to bron- chial irritation. In sensitive irritable subjects labouring under bronchial disease, we generally find a corresponding state of the pulmonary organs; we have little expectoration, with a disproportion- ate degree of irritation and cough from the slight- est exciting causes. A dry and sharp atmosphere in such cases cannot be borne, while a mild and even humid air often gives relief. In persons of a more languid habit, suffering under the same disease, we find less sensibility of the mucous membrane, and a much more copious expectora- tion. The same dry and keen air which proves so irritating in the former case is beneficial in this. Were we to prescribe for the name without giving due consideration to the nature of the disease and the constitution of the patient, both these invalids might be sent to the same place, the one to be injured as much as the other would be benefited. What has just been said of bronchial affections is equally applicable to dyspepsia, rheumatism, con- sumption, and several other diseases. It would be wasting the reader's time to point out the important practical inference to be drawn from these observations. In recommending change of air, the next cir- cumstance which presents itself for our conside- ration is, the relative preference to be accorded to a situation in the interior of our inland, or on the sea-coast. The season of the year will assist us in deciding this point. Generally speaking, the more sheltered parts of the interior form the most eligible residences, to all classes of invalids, during the spring and early part of summer : after mid- summer, in the autumn, and during the winter, the sea-side affords the best situations. This, however, is only to be considered as a general rule, to which there are many exceptions. Whe- ther the situation selected be inland, or on the coast, the particular characters of its air must be such as are. suited to the patient, as very consider- able differences exist in places situated at no great distance from each other, both in the interior and on the sea-shore. There are also peculiarities of constitution, which we can only learn from inform- ation communicated by the patient. Some per- sons, for example, never feel well by the sea-side in any situation, or at any season, although to all appearance their ailments are such as we know to be generally benefited by a marine atmosphere; while others improve during a residence on the coast under the most unfavourable circumstances of situation and season. But there are few persons who require change of air, either with the view of preventing disease, or of removing its effects, that will not derive greater benefit from repeated changes, than from a long continued residence in any one situation, however judiciously selected. The more sheltered and drier parts of the interior during the spring, the more elevated and even mountainous districts in the summer, and the south and south-west coasts of our island during the autumn and winter, afford a succession of changes capable of effecting much benefit in numerous cases in which the other measures of medicine are of little avail. It is to be regretted, however, that but a small pro- portion of invalids, or of the more delicate of our youth, can avail themselves of a change of air upon so extensive a scale as we have just been 70 AIR, (CHANGE OF) contemplating; the rather because it affords one of the most powerful means of improving the general health, and obviating the disposition to tuberculous disease, which we possess. But here it is proper to observe that the best directed change, or succession of changes, of air, will produce little permanent benefit unless strict attention be paid to regimen, more especially as regards diet. Too much is generally expected from the simple change of air, while little atten- tion is paid to the various circumstances compre- hended under the term regimen, although these are equally essential to the restoration to health as the measure from which so much is anticipated. It should be strongly impressed on the minds of such persons as seek benefit from change of air, and more especially upon dyspeptics, the most numerous class of all, that, without adhering to the regimen laid down for them, they will derive but little advantage from the most favourable change of air. Many may, indeed, find their limbs stronger and their general health improved, and even the more urgent symptoms of their dis- ease may cease to prove troublesome ; yet all these improvements will too often prove but fleeting, and their return to their usual avocations will soon be followed by a return of their old complaints. The restricted limits of this article will not allow us to particularize all the diseases in which change of air proves useful; there are few, indeed, to which it is not applicable at some period of their course. The good effects of this remedy, when well directed, in the morbid states of the mucous membrane of the respiratory organs, are well known ; and they are scarcely less remark- able in disorders of the digestive organs, and of the uterine system. In the functional derange- ments of the nervous system, also, whether origi- nating in the diseases just alluded to, or the conse- quence of sedentary and confined life, change of air will be found a powerful means of restoring the tone of the system. In all these cases, indeed, it is a remedy for which we have no adequate substitute. [In all diseases in which the affection appears to be kept up by habit, in other words, by accus- tomed associated actions, and especially in those that implicate the nervous system, the beneficial effects of change of air are proverbial, and are acquiesced in by all observers. It is probable, that a great portion of the salu- tary effects ascribed to the waters of fashionable summer retreats is dependent upon change of air, and other extraneous circumstances. Long before the citizen of one of the Atlantic towns reaches the Alleghany springs of Virginia, he has an earnest of the advantages he is about to derive from change of air; and many a valetudinarian finds himself almost restored during the journey, fatiguing as it is, through the mountain regions which have to be crossed before he reaches the White Sulphur, in Greenbrier county. Many persons, too, cannot drink the water with impu- nity, and are consequently indebted for their im- piovement chiefly to change of air, but somewhat, also, to varied scenery and society, absence from cares of business, and to greater regularity of living, perhaps, than they have been accustomed to. In making these observations, it is not designed to affirm that mineral waters, as in the case of the valuable spring in question, may not occasionally be important agents in the cure of disease ; but, taking invalids in general, we are satisfied that more is dependent upon change of air than upon the administration of the waters. The inhabitant of one of the Atlantic cities, and of most of the districts to the cast of the Blue Ridge, removes from a hot atmosphere to one which is compara- tively cool, and where all the diseases that are common to hot and malarious climates are ex- tremely unfrequent, and many of them unknown. The advantage is obvious. He escapes the dis- eases which might have attacked him had he remained through the summer in his accustomed locality ; and hence the wealthy families of Lower Virginia are in the habit of spending those months in the mountain regions in which they are espe- cially liable to disease in their own malarious dis- tricts. We can thus understand the reputation acquired by the inert Bath and Matlock waters of England, the latter of which has scarcely any solid ingredient ; and yet what crowds flock to these agreeable watering-places; to the former, for the perpetual amusements, that keep the mind engaged, and cause it to react beneficially on the corporeal or mental malady ; to the latter, for the enjoyment of the beauties of nature, for which Derbyshire is so celebrated. It is obvious, that were such waters bottled, and sent to a distance, so that the invalid might drink them at his own habitation, the charm would be dissolved. The garnitures—more important, in this case, than the dish—would be wanting, and the banquet would be vapid, and without enjoyment or benefit. Less than twenty years ago, amidst the bubbles that were engaging the minds and the money of the English public, it was proposed to carry sea-water, by means of pipes, to London ; in order that the citizens might have the advantage of sea-bathing without the inconvenience of going many miles after it. Had the scheme been carried into effect, the benefits from metropolitan sea-bathing would not have exhibited themselves in any respect comparable to those of the same agent employed at Brighton or Margate. (Dunglison's Elements of Hygiene, p. 157. Philad., 1835.) It would seem, therefore, that a mere change of the physical circumstances of the atmosphere ! in which we are habitually placed, is advantageous | to the economy, and that the vital forces act with j increased energy, whenever we leave a locality to which we have been long accustomed, and where the functions are executed under the influence of unvaried excitants, and pass to one differing essen- tially from it. Nor is it always necessary that this difference should be extensive. Sir James Clark remarks, (The Sanative Influence of Cli- mate, &c, 3d edit. p. 315: Lond. 1841,) that notwithstanding the uniformity of temperature which prevails among many of the West India j islands, the effect of a change from one to another : is often very remarkable in improving the health, , —a fact frequently observed on a large scale, among the British troops stationed in the West Indies ; and he considers, that one of the most powerful means of diminishing the sickness among the troops, in that climate, would be to remove them frequently from one healthy island to an- other. ; The moral and physical effects of change of air, ALOPECIA. n during travelling, have been well depicted by Dr. James Johnson. (Change of Air; or the Philo- sophy of Travelling, &c. ; Amer. edit.: New York, 1831.)] But change of air is not more valuable as a remedy in the cure of disease and its consequen- ces, than as a preventive of disease, more espe- cially in childhood and youth. At this tender and susceptible period of life, the rapid influence of the atmosphere in which we live, in deteriorat- ing or improving the health, is very remarkable ; a change of a few weeks from the country to a large town being often sufficient to change the ruddy, healthy child into a pale, sickly-looking creature, and vice versa. The comparative in- fluence of a town and country air on the health of children is seen in a striking manner in the families of the higher ranks of society, who spend a considerable part of every year in town. Chil- dren should never be reared in large towns, when this can be avoided ; and when unavoidable, they should be sent, during a part at least of every summer, into the country, which, indeed, is the proper place for children, until their system has acquired sufficient strength to resist the injurious effects of city life. When they cannot have this advantage, we consider it the duty of the medical attendants of families to urge a temporary annual residence in the country, as essential to the health of children, more particularly those who are deli- cate. How many neglect this invaluable means of improving the health of their offspring, who have it in their power, and would willingly adopt it, were they aware of its importance ! So strong- ly, indeed, are we impressed with the value of this measure from ample observation, that we consider parents resident in towns, who have the means of giving their family the advantage of country air, and neglect it, deficient in one of their chief duties. To young females, who, by the habits of society, are much more confined to the house than boys, a temporary annual residence in the coun- try becomes a measure of still greater importance, and should be continued at least to the full period of their growth. We have reason to believe that the advantages of country air to the young and delicate are not yet sufficiently appreciated by the profession, and we are therefore anxious to call their attention to it, that they may use their in- fluence with the public, upon whose minds if they succeed in impressing the full value of pure air, they will be the means of contributing greatly to the health of the rising generation. James Clark. ^ALOPECIA—The falling off of the hairs, in an unusual degree, from any part of the body naturally covered with them, constitutes the essen- tial character of this disease. The name, which I is derived from aXtinri!-, vulpes, because the fox, when grown old and during summer, has been observed to be subject to this complaint, has, since the time of Sauvages, been used as the generic i term of the disease ; but, by the Greeks and Celsus, it was originally confined to one of its species.* * De Medicina, lib. vi. cap. 4. Aetiur, Tetrab. 2, Sermo 2, 55. Piso, de roun. et curand morbis, lib i. cap. 1 Orihas. de loc. allVrt. rur. lib. iv. cap. 42. Paul. lib. iii. cap. 1. Serapion. lib. i. cap. 1. Mercurialis, lib. i. cap. 4; lib. vi. cap. 4. Svn. Fluxus Capillorum, Areee (Celsus); Tyria (Arab.) ; Athrica, Depilatio, Defluvium Pilorum, Pelada, Pilarclla (Auct. Vur.) ; Pelade (Paree) ; Alopecia (Sauvages) ; Calvities (Teu- tonici); der Kahlkopf, (Plenck) -. Trichosis Area (Good); Gangrena Alopecia (Young) ; Baldness. The different manner in which the hairs fall, the state of the skin from which they fall, and the healthy or unhealthy state of the hairs them- selves, lead to considerable variety of form in the disease. Sometimes the hairs are shed irregular- ly and indiscriminately, producing only a general thinness of the hair; to this Celsus applied the descriptive term, fluxus capillorum.-f Sometimes parts of the body are entirely deprived of their hairs, presenting smooth shining patches perfectly bald ; these are the area? of Celsus, (Lib. vi. cap. 4.) the alopecia areata of Sauvages, the porrigo decalvans of Willan. When the spots of bald- ness observed no particular form, although usual- j ly they are nearly circular, they were denoted by Celsus, after the Greeks, dXwncieia; $ but when they presented a lengthened serpentine form, gen- : erally commencing on each side of the occiput, and sometimes continued until they united in front, the term iplaan was applied to them.§ Sometimes this disease is universal, leaving not a single hair upon any part of the body ; (Welfs Tr. Soc. Med. and Chi. Kn. u\ 264.) in which I case it was called, by the French, la pelade ,- although some will have it that, with the falling of the hair, a desquamation of the cuticle was j also meant by this term. Sometimes the baldness i is confined to one particular part, most commonly to the hairy scalp, when it formerly received the | name of tfiaXdicptao-is or waSdpwaic; sometimes to the eye-brows, eye-lashes, or other parts of the body. The fall of the hairs may take place more or less rapidly ; sometimes in a few days, and even in a shorter period, the body has been known to lose all its hairs ; sometimes the change is slow and imperceptible. Sometimes the skin, from which the hairs fall, presents the ordinary appear- ance—smooth, shining, without redness or altera- tion ; sometimes it is pale, of a dead white colour, and furfuraceous ; sometimes it is covered with a scaly scurf like pityriasis, which, when removed, exposes an erythematic appearance ; sometimes the skin is natural in sensibility, and sometimes it is affected with itching, or a sense of pricking or pungent acrid heat. Sometimes the hairs, before falling, as well as those which remain, pre- sent an unhealthy appearance ; at other times no alteration can be perceived in them, and those which surround the bald spots are as strong and healthy as natural. Nor are these distinctions trivial or of little help ; for they are all connected with particular causes and particular conditions of the body, and, therefore, lead to precision of treatment. The immediate, cause of the falling of the hairs is unquestionably a diseased state of the follicles which nourish and support their bulbs, having the same relation to them as the capsule or membrane t Loc. Citat. lib. vi. rap. 1. Trallian. i. i- Actuar M. M. ii. 5; iv 9. Oribas. iv. 5. Fernet. Consul, i. 1. I Id. loc. citat. Galen, de Cur. Morb. sec. loc. lib. i cap. 2. § Celsus, loc. citat. Oribas. de Loc. Affect. Cur. iv 42 ; viii. 22, 24. Actuarius, M. M. v. 13. 72 ALOPECIA. which surrounds the roots of the teeth, (for the process of the formation of the teeth and the hair is perfectly the same) ; but the precise nature of the diseased state has not been determined. It would seem to depend sometimes upon inflamma- tion of the follicles, sometimes upon their ulcera- tion, sometimes upon a temporary deficient action, and sometimes upon atrophy or death of the folli- cles. In the body of a man who had become almost entirely bald in consequence of a putrid fever, of which he died, Bichat observed all the pilous follicles in their natural state, and small hairs shooting forwards from their bottom ; but he remarks that, before the fall of the hair in aged people, the cavity of the bulbs of the hairs gradu- ally diminishes, and the follicles, which contain the bulbs, at last disappear. The destruction of the pilous follicles may, however, be caused by pressure, by friction, and by other causes. Thus it has been observed to be produced by the pres- sure of certain subcutaneous tumours. Alopecia may be a purely local and idiopathic disease ; the affection originating in the follicles themselves. This happens when it arises from external causes, as from the application of quick lime or other depilatories; from the fumes of quicksilver, as was observed by Forestus in gold- smiths; from exposure of the head to the rays of the sun ; from frequent pressure of weights upon the head; and from friction of any hairy surface by the garments or otherwise. Or it may be local and consecutive, as when the follicles are injured by becoming involved in the inflammation, ulcera- tion, or other morbid process of any adjacent cutaneous disease, as happens in porrigo, im- petigo, variola, eczema, elephantiasis, and several others. Alopecia may also be secondary and symptom- atic, a consequence of general debility and con- stitutional exhaustion ; and hence it attends the convalescence of febrile diseases, and the puer- peral state ; hence, also, it is a common symptom of the advanced stage of phthisis, of diabetes, and of most cachectic diseases ; thus justifying the prudence of the Romans, who estimated slaves affected with alopecia at the lowest price. Hence it is also observed in the nervous debility which follows excessive venereal indulgences or seminal emissions, and has been known to be produced by painful and distressing headachs ; by long con- tinued and intense study ; by the depressing pas- sions, as fear; by cares, disappointments, and anxiety. Of this kind was evidently that singular case related by Ravator, of a person, who, after a violent commotion, was attacked with amaurosis of the right eye, and all the hairs of the same side of whose body lost their colour, and fell from the eye-brows and eye-lashes as well as from the head. Of the same nature, also, was, in all probability, the remarkable case of M. le Chevalier d'Epernay, (Gazette Francois, Feb. 23, 1763.) who, after an assiduous application for the space of four months, without any previous symptom of disease, lost his beard, his eye-lashes, his eye-brows, and, in short, all the hair of his head and body. Alopecia may be a sympathetic affection, not a symptom of a constitutional disease, but caused by a disease or disordered state of some other organ or system of organs. The most common form of this description which has come under our observation, is that which proceeds from chronic inflammation of the mucous membrane of the stomach, giving rise to a particular form of dyspepsia, which has. for this reason, been called inflammatory. Of this nature, probably, was that mentioned by Galen, (De Cur. Morb. Sec. Loc. lib. i. cap. 2.) arising from eating poisonous mushrooms; and that other noticed by Hippo- crates, (De Internis Affectibus, sect. 4.) in which the reader will readily recognize a well-marked case of the above-named form of dyspepsia (gas- trite chronique), and to which case there is, in an excellent record of modern medicine, (Journal des Progres, 1830. torn. ii. p. 43.) a parallel in form as well as in cause, and which, it is deserving of attention, was afterwards succeeded by an attack of diabetes mellitus. Of the same nature also was in all probability that species of alopecia termed by the Arabians (Avenzoar, Avicenna,) bilious, in contradistinction to the other species which they called phlegmatic,- which last, in all appearance, corresponded with that form described by Celsus as most difficult of cure, " pejus est quod densam cutem et subpinguem ex toto gla- brum facit," coinciding with the observation of some modern writers, that if the skin is pale or insensible, and it is difficult by friction to produce redness, the case is irremediable. Of the same nature is the case given by Lemery, of a man, who, some months after excessive catharsis, lost successively all the hairs from his body; and also another strikingly singular case, which, both in its causes and its cure, justifies the opinion which we have ventured to give of the nature of this species of alopecia. It is so illustrative that no apology is required for relating it. " Lodovico Gnemmi, a Piedmontese, fifty-seven years of age, a person of great vivacity of temper, of a plethoric habit, but spare form of body, having the skin of a dull white colour, began, in the winter of 1825 and 1826, to feel severe pains in the head, with a sensation of burning heat over all the body, but most particularly in the skin : it was to such a degree, that, during the coldest night of winter, he was obliged to throw off his bedclothes. After having passed fifteen days in this painful state, he began by degrees to lose all the hairs of his head, then those of the beard, eye-brows, eye-lashes; and in the course of a month, there was not to be found a hair upon the surface of his body, neither in the arm-pits, on the breast, on the genital organs surrounding the anus, nor upon any of his extre- mities. All his skin was as smooth as polished \ marble, and the slightest trace of hairs could not be felt by the hand. He remained for two years in this state, so deformed by the loss of his hair that he hardly ventured to show himself in public, but always feeling on the surface of his body a j sense of pungent acrid heat, more especially on I the surface of the scalp, which was always mor- I bidly sensible and painful to the touch. In the i beginning of March, 1828, he was attacked with | a severe peripneumony, which was treated and - cured by the most active antiphlogistic remedies, j viz.: low diet, general and local blood-letting, cupping, purgation, blisters. &c, and, strange to say, under the influence of this treatment, on the .decline of so severe an inflammatory disease, and , in a state of the greatest weakness of the cir'cula- I tion, the hairs which had disappeared for the ALOPECIA. 73 space of two years, began again to shoot forth, and continued to do so during all his conva- lescence. On their first appearance they resem- bled fine soft wool, almost colourless wool; but they continued every day to approach nearer to their natural character, which they had fully re- covered at the end of a month, when, owing to some imprudence in regimen, he was seized with an acute attack of gastro-enteritis, which carried him off." (Journal des Progres, torn. xiv. p. 244.) Of the same nature, also, are many cases of partial alopecia (porrigo decalvans) which we have observed in adults as well as in children, and which we have had the satisfaction of remedying by treating the primary disease—chronic gastritis, or inflammatory dyspepsia. This origin of alopecia also accounts for the connexion which we have observed between it, lichen, urticaria, and pityriasis; sometimes co- existing ; sometimes succeeding each other ; all differently modified operations of the same cause. To this description of alopecia ought probably to be also referred' those which have been attri- buted to the use of certain kinds of food, and which have been said to prevail at particular places. Thus it is said not to be unfrequent in countries where the inhabitants live chiefly on fish ; as, for instance, formerly in the Shetland Islands* where baldness from this cause was so common that it was a familiar saying that " there was not a hair between them and heaven." (Sir R Sibbalds Description of Shetland.) Thus Tournefort relates, that in the island of My cone, one of the Cyclades, the children are either bald, or seldom arrive at the age of twenty without being so. And, though it is difficult to assign the cause, it must be acknowledged that alopecia (porrigo decalvans) has appeared to be more com- mon at Brighton than in other places, and that all the cases the writer has observed in this place have afforded symptoms of chronic irritation of the mucous membrane of the stomach. Besides the causes of alopecia which have been enumerated, in distinguishing its different kinds, there is one which has been observed by Dr. Willan and others, not easily referred to any of them. It is when the disease appears to have originated in the infection of porrigo scutulata; for when this disease has spread through large schools, in some instances, one or two of the children have been affected with alopecia (porrigo decalvans). We have purposely avoided placing amongst the causes of alopecia the influence of age, which belongs more to the ordinary course of nature than to a process of disease, as well as another cause which is said to have a wonderful power in modifying the growth of the hair. We allude to the circumstance of eunuchs, when the mutilation takes place in infancy, having no beard, and yet never becoming bald ; a change which is more properly considered a deformity than a disease, but showing a singular connexion between the growth of the hair and the develop- ment of the genital organs, of which, however, the perfect state of the body affords many proofs. There is, however, one species of alopecia which, properly speaking, ought to have been arranged amongst the symptomatic forms of that disease, but which, on account of its specific Vol. I___10 u nature, has generally been separated from it — alopecia syphilitica. The falling of the hairs is one of the most rare of the secondary symptoms of syphilis, so much so that it is seldom met with —not oftener, it has been calculated, than once in fifteen hundred cases. M. Cullerier, of the Hopi- tal des Veneriens at Paris, who was for twenty- five years in the habit of seeing from two to three thousand venereal patients every year, states that, upon the whole number, he had not met with more than three or four cases of universal alopecia, and from fifty to sixty cases of partial alopecia. Nor was it observed amongst the symptoms of that disease upon its first appearance in Europe ; for, either unknown or at least unnoticed before, it was not until towards the year 1538 that it attracted the attention of observers—of Rangon, Fallopius, Massa, Brassavola, and Fracastorius. From that period it seems to have gone on in- creasing to the end of that century or to the beginning of the next, since which time it has been progressively decreasing, and has almost entirely disappeared in temperate climates ; but, if we may place confidence in some accounts, it is less rare in warmer regions, as in Egypt, the southern provinces of Italy, and Spain. It is however not entirely unknown amongst us. Cases are to be found in the works of most medical writers; one of the most recent is that of Professor P. Metons. (Clinique Chirurgicale.) When this form of alopecia first fixed the attention of observers, it was matter of dispute whether it was a consequence of the disease or of its specific remedy ; but though it appears, par- ticularly from the cases of Forestus, that alopecia may be produced by mercury, there are not want- ing cases to prove that it has followed syphilis when this remedy had never been resorted to; and its cure by mercury is a strong converse proof that, if it ever arises from it, it is only under very peculiar conditions. The syphilitic alopecia does not in itself present any peculiarity to distinguish it from the other forms of that disease. It is generally preceded or accompanied by a furfuraceous state of the skin, from which vast quantities of small scales are daily thrown off, in the form of bran, and daily reproduced, and the skin underneath is observed to be redder than natural. But the cotemporane- ous existence of other symptoms of the venereal disease, and the history of the case, will afford the best data for diagnosis. It might be inferred, from the great number and the diversity of the remedies which have been used and recommended for the cure of alopecia, that the method of cure was very uncertain, or the forms of the disease very diversified. As the con- clusion is usually drawn from these premises, this latter inference is generally overlooked. But if we admitted it, as we ought, it would lead us not always to throw aside the multifarious farrago of our predecessors as so much useless rubbish, but direct us to seek in the varieties of the forms of disease for the reasons of the application of such various remedies ; and, in our opinion, by recon- ciling in this way the diversity of the disease with the diversity of the methods of treatment, we should entertain a better opinion and make a better use of past experience. 74 ALOPECIA—ALTERATIVES. Treatment.—From the distinctions of the different forms of alopecia which we have endea- voured to point out, may easily be understood how it may sometimes have been cured by phlebotomy; by local depletion, as leeches, scarifications, and acupuncture ; by purgatives, low diet, and other antiphlogistic remedies: how, at other times, simple local means may have succeeded better, as friction, no matter whether with the fat of the mole, the snake, the hedgehog, or the bear; or with warm exciting substances, as camphor, tur- pentine, naphtha, laudanum, resin; with volatile oils, as those of laurel, rosemary, mace, or cinna- mon, or with the distilled water of bees-wax; with acrid substances, as thapria, euphorbium, staves- acre, nasturtium, mustard-seed, garlic, onions, and tincture of tobacco ; with irritating applica- tions, as friction with fig-leaves, nettles, tincture of cantharides, and even the application of a blis- ter : how at other times advantage may have heen derived from alkaline ingredients, which explains the use of the laxivia of wood ashes, of burnt cane, of the burnt hair of bears, and of applications containing the bile of different animals, and the ordure of birds, as the ancient remedy of stercus columbinus.- how at other times such astringent applications as alum, cimolian earth and wine, or green vitriol, the atramentum sutorium of Celsus, may have answered better; and how, whatever be the form of the disease, or the nature of the treat- ment, the frequent shaving of the diseased parts, which has been recommended by all writers, is a remedy always applicable. When there exist signs of an inflammatory state of the pilous follicles, or erythema of the surrounding skin, leeches may be applied with benefit, and a course of purgative remedies is of great service. But when the disease of the folli- cles appears to arise from an inflammatory state of the mucous membrane of the stomach, leeches must be applied to the scrobiculus cordis, and a regimen of mild bland diet must be insisted upon. In the first case the best local application is any mild demulcent liquid, as decoction of bran, or mallows. But when the skin, from which the hairs fall, indicates a deficient degree of vitality, the parts may be excited by local stimulants. (R old macis ^ii. alcohol: giv. M.) Pencilling the surface with a solution of nitrate of silver, or rubbing it with a liniment of olive oil, and as much nitric acid as makes it pungent, but not acrid, have been found to answer the same pur- pose. ' Of the use of the celebrated oil of Macas- sar in such cases we have no experience, but the solution of sulphate of copper in alcohol, lately very much recommended by a German physician, has failed in our hands. When the skin is fur- furaceous, or the cuticle hard, shining, and imper- meable, like parchment, it is of great use to wash it frequently with some alkaline or sulphurous solution (R Liq. ammonias acetatis f.^ii. ammo- nias carbonatis gii. alcohol.- f.gss. aq. fontan .- f.£i\. fiat lotio.) But when either of the foregoing states of the skin is connected with a deranged state of the general health, it is unnecessary to say that this demands the chief attention. When alopecia acknowledges a syphilitic ori- gin, the specific remedy of that disease must be had recourse to, exhibited in as mild a form as 1 possible. For the direction and means of effecting this, we refer to the treatment of Acxe syphilitica. The local applications in this form of the disease [ differ in no respect from those suited to the ordi- ' nary species, except that a few grains of corrosive sublimate may sometimes be advantageously com- bined with them; and frequently shaving the 1 diseased skin is a part of the treatment which cannot be dispensed with. rp j foDD ALTERATIVES. — This term, although not ' expressive of a distinct class of medicines, is so I frequently employed as to require particular ex- planation. By an alterative course of treatment is commonly meant the continued exhibition of I certain medicinal agents supposed to have the power of altering certain disordered actions, chiefly i of a chronic character ; and all medicines possess- ing, or supposed to possess, such a property, no j matter to what class in the Materia Medica they may otherwise belong, are occasionally denomi- nated alteratives. Although the term is often used vaguely, the indication with which an altera- tive medicine is prescribed is of the utmost im- portance. It might be said, indeed, in general terms, that all remedial means whatever are alterative, but the alteration sought from the use ' of specific alteratives, or of alteratives in the re- stricted and ordinary acceptation of the Aerm, is such as is not readily, or at all, to be obtained, by general or local bleeding, by purgatives or diu- j retics, by tonics, anodynes, or antispasmodics; although the agency of particular medicines be- | longing to any of these classes is sometimes made subservient to an alterative course of treatment. Mercury, in all its various forms, is one of the medicines most commonly employed as an altera- tive; and the great influence it exerts on the whole economy, over all the secretions and excre- tions, and over the nervous system itself, consti- tute it an alterative, when prudently given, of a most efficacious kind. Even in certain states of fever, mercury has been employed with success for the restoration of the secretions, and, there- fore, it may be said, as an alterative. In chronic inflammation, although here, perhaps, the term alterative may be objected to, small doses of the pilula hydrargyri or of calomel are often consid- ered highly serviceable : no cases are more fre- quent than these, and in none is the practitioner more in need of some means of checking or alter- ing actions, which, although neither violent nor immediately dangerous, are silently effecting struc- tural changes and irreparable mischief. It would certainly appear that, for this purpose, the major- ity of practitioners rely on the efficacy of mercury, often in combination with opium. In certain in- stances, of which chronic laryingitis may be cited as an example, as well as in the instances of new formations, even of a malignant character, the addition of a medicine possessing narcotic proper- ties may be useful on the principle of allaying the disturbance of the nervous system, a disturbance but little regarded or acknowledged in such cases, but probably intimately connected with the pri- mary functional disorder in which all morbid changes of structure, and even inflammation itself, must commence. Most persons of experience in medicine have met with examples of chronic dis- ALTERATIVES. 75 orders of a troublesome rather than of a danger- ous nature, which have been ameliorated, or en- tirely relieved, by the persevering use of some of the forms of mercury ; although the medicine may have been given at first without any other reason than that it afforded a chance of benefit. Even irritable states of the bronchial and intesti- nal mucous membrane certainly sometimes give way under this treatment; but the application of it requires that caution of which nothing but ob- servation can teach the value. The advantage obtained in such cases, and in others not unfre- quently met with, from the apparently indiscrimi- nate employment of calomel, may eventually be found to depend upon some general law, which has not yet been explained ; or simply, as we be- lieve John Hunter thought, one kind of irritation superseding another, and banishing it from the system. No medicine is so commonly given in disease of the mesenteric glands as calomel; it is by no means rarely administered in scrofula ; not- withstanding the general opinion of the unfavour- able influence of mercury on the scrofulous con- stitution ; and notwithstanding the common ac- companiment with mesenteric disease of a state of intestinal irritation or of chronic inflammation. In almost every varied disturbance of the liver, mercury is one of the first medicines to which many practitioners have recourse, and in the form of the pilula hydrargyri it has been recommended in many disorders of the digestive functions. A practice so common must have been supported by many cases in which it was found useful, although the principle on which the medicine acts, if it be not that of suspending morbid actions, is, in some of the cases, not very easily imagined. In the case in which acute inflammation of membranous parts is checked by the employment of calomel; or depositions, the consequences of such inflam- mation, are removed, of which iritis may be men- tioned as presenting a striking illustration; this medicine is given to produce a precise effect, which experience has shown to arise from its use. In the chronic forms of indigestion, its operation on the secretions seems to explain the great advan- tage often arising from it. In the other cases, cases of mere irritation, or cases in which there is a disposition to new formations not ascribable to inflammation, the same medicine is given, often with the same good effects ; but the actions which are then interrupted being less understood, the medicine is only called an alterative. Antimony is very often employed in the class of cases just spoken of, although not in them ex- clusively, as an alterative ; generally in combina- tion with calomel. The benefit of this combina- tion is usually ascribed to an alterative effect pro- duced by them in the secretions into the intestines, and in the cutaneous exhalation ; in other words, in the functions of the bowels and the skin. The pulvis antimonialis is, perhaps, most frequently used with this indication in extemporaneous pre- scription ; and a very useful preparation, the anti- monii sulphuretum praecipitatum, is conveniently united in the pilula hydrargyri sub-muriatis cotn- posita, with calomel. In this, the celebrated Dr. Plummer's pill, we meet with another alterative in the guaiacum, which, as well as the sassafras, the mezereon, and sarsaparilla, although not so extensively useful, is certainly of singular utility iu some chronic affections. Daily observation shows the obvious effects of the Plummer's pill on the bowels and on the skin : the most observ- able of the immediate effects of the sassafras and the sarsaparilla are produced on the skin, although some effect may occasionally be observed equally early on the intestinal and renal secretions. The taraxacum is a medicine not unfrequently given in chronic affections of the stomach or the liver ; I and its sensible, as distinct from its alterative ac- tion, appears to be greatest on the urinary secre- tion. In the alkalis we have another description of medicines, often prescribed as alteratives, par- ticularly to scrofulous patients affected with dis- ease of the glands of the neck or of the mesen- tery, or with diseases of the joints. The carbo- nates of soda and potass, and sometimes the liquor potassee or the liquor calcis in combination with sarsaparilla, or with some of the bitters, are pre- scribed in such cases, and probably produce their good effects by first acting on the stomach itself. But there can be no doubt that all these medicines have an ultimate effect which in reality entitles them to the name of alteratives. This effect, which may be simply expressed by the phrase of altering morbid actions, may be secondary to their action on the stomach, or on the skin, or on both these surfaces ; or it may be primary. Accurate observations on the states of the blood in disease are too infrequent to enable us to speak with con- fidence of the alterative effects of medicines on that important fluid. It is, however, highly pro- bable that the effects of some at least of the alter. atives are secondarily, and of others primarily produced on the blood itself. In many of the diseases in which they are most employed, and most useful, there is an evident impairment of secretion. Secretion, although partly dependent on certain nervous actions, demands, for its per- fect performance, a healthy state of the blood, the fluid in which and out of which all the various constituents of the various secretions are created. Supposing that from some disorder in the blood, we have produced, certain varieties of disease on the surface, or in the stomach or intestines, or in the bones, ligaments, cartilages, or other solids of the body,—the effect of a medicine which removes such diseases must be to alter that first morbid condition of the blood; and thus to cause healthy secretion and excretion, instead of cutaneous dis- ease, or chronic indigestion, or venereal nodes in the tibia, or increased vascularity and depositions affecting the motions of the joints, or any other morbid action or formation for the prevention or cure of which we prescribe alterative medicines. Such, then, generally speaking, must be the ac- tion of alteratives. They may amend the state of the blood by previously improving the functions of digestion and assimilation ; or they may directly affect the process of sanguification, a process yet imperfectly understood ; but that alteratives do actually change and improve the state of the blood in many instances cannot be doubted. We find in such facts, admitting them to be so, an expla- nation of the term depuration, attenuation, &c, used by the older writers, and also of the more popular expressions of " sweetening" and of " clearing" the blood ; and in these terms we have 76 ALTERATIVES. a p^oof how long such an opinion has appeared reasonable to pathologists, and how supported the opinion is by common belief, founded upon com- mon observation. But supposing the nervous action which has been spoken of, as essential to the proper perform- ance of secretion, to be disordered in cases in which alterative medicines are commonly consid- ered to be indicated,—it may still be understood how this functional office of the nervous system may also be more efficiently performed when an alterative medicine has corrected the disordered state of the intestinal canal; and there are not wanting facts of a nature to incline us to ascribe the influence of some medicines employed as alter- atives, to their direct operation on the nerves. Whether the use of hemlock in the case of some tumours, and the effects of the prussic acid in cer- tain examples of phthisis pulraonalis, may not be of this kind, is at least worthy of some consider- ation. That the addition of a small quantity of the extractum hyoscyami, or of the pulvis ipeca- cuanha compositus, to alterative doses of the pilu- la hydrargyri, in certain forms of dyspepsia, is serviceable in this way, seems hardly to admit of doubt. Physicians of great authority, among whom may be mentioned Dr. Heberden, have laid it down as a rule to be observed in the management of obstinate chronic disease, that we should with all care regulate the different functions of the body, diligently observing any departure from their com- mon and healthy condition; and thus place the constitution as nearly as we can in that state in which its own efforts may be put forth for the cure of such persevering and otherwise intractable mal- adies. It may at least be said, that this is often all that the practitioner has it in his power to do; and it might sometimes be advantageous to the practitioner, as well as to the patient, if the former would limit his ambition by recollecting this. If the obscurity in which internal changes are effect- ed, weakens the evidence in many medical cases, the annals of surgery abound with instructive proofs of the extraordinary local benefit arising from this kind of treatment. This is that consti- tutional treatment, in fact, which Mr. Abernethy succeeded in introducing into surgical practice ; and although the disciples of that distinguished pathologist, and even he himself, may sometimes have carried the principle too far, its foundation is not.weakened either by their erroneous zeal or by his eccentricity. Another rule, less scientific, and less safe, and emanating from authority less to be depended upon, is, when a disease does not readily yield to com- mon treatment, to make some great impression on the constitution, in the hope that, in the general commotion and agitation, disordered actions may be rudely interrupted, or the actions of health feli- citously restored. Without entering into any discussion concerning the propriety of the rule, which might perhaps admit of justification even as leading merely to the introduction of a new irritation, its principle is unquestionably alterative. Various means have been employed to produce the desired effect,—a large bleeding, a large dose of mercury, a powerful opiate, or repeated and large dc ses of metallic tonics. All of these, and other measures adopted with the same intention, have, we doubt not, been occasionally serviceable. Of the advantageous operation of some of them we have been witnesses ; particularly of the use of a large dose of mercury in very obstinate sci- atica, and of opium in some old and unmanage- able cases of epilepsy. There are certain auxiliaries to medical treat- ment, which are frequently used with all the in- dications which have been specified as pointing to the employment of alteratives. Thus, change of air, sea-bathing, alterations of habitual clothing, and sudden or considerable changes in diet, are frequently recommended, and with the best effects; sometimes producing benefit by acting on the stomach or on the skin; sometimes by-acting more directly on the blood, or on the nervous system ; sometimes by improving the state of the secretions or excretions ; sometimes by removing some obstacle to the proper performance of some particular function ; and sometimes by producing a new and strong impression on the body or the mind. Many of these advantages are simultane- ously obtained by taking the various mineral waters. Change of place, and temporary change of habits, freedom from business, and the gentle excitement of novel forms of amusement, doubt- less very powerfully conspire to produce the sin- gular improvement of health so often observed in patients resorting to Cheltenham, Leamington, Tunbridge, Malvern, Harrogate, and other cele- brated watering-places; although still a part, and often a very considerable part of the improvement is evidently to be ascribed to the daily and mode- rate excitement of the stomach and bowels, and, in some cases, of the kidneys, by the ingredients of the mineral water itself, which thus acts as a most valuable alterative of the whole system. That the external application of the waters stimulates the skin to new action, and thus pro- duces direct relief, and, in this way, or by sym- pathy, improves the tone of the stomach, or effects more extensive improvement, must also, we pre- sume, be admitted. The class of chalybeates contains agents which have an evident effect on the circulation, as tonics. Given, however, in the minute state of subdivision in which they are held in solution in natural springs, they produce effects which entitle them to the name of alteratives. They excite the cir- culation, which was before languid, and, in all probability, they alter and improve the condition of the blood. Either directly, or through their first action on the sanguiferous system, or by some direct or indirect influence on the actions of the nervous system itself, or in more than one of these ways at once, they stimulate the secre- tions, which were before scanty and imperfect; and they more manifestly'alter the state and ap- pearance of the body than any other medicines whatever. In conditions of the body suited to their use, no alteratives are, in fact, so effectual. j They substitute general energy for general debility, and revive the colouring of health in patients [ before pallid, or wan, or discoloured, as in the chlorotic, by long disease. The illustration of an alterative by reference to remedies of this class, shows, however, the impossibility of effectually dividing alteratives from other classes of medicines. ALTER./ When medicines are intended to act as altera- tives, they are usually given in small doses, re- peated every night for some weeks ; such, at least, is the general mode of prescribing alterative doses of calomel and the antimonial powder. From two to five grains of either are frequently pre- scribed in this way, to adults, but most common- ly the smaller dose of both. Five grains of the Plummer's pill contain rather more than one grain of calomel and of the precipitated sulphuret of antimony, and two parts of guaiacum. In many cases of disordered digestion, small doses of the pilula hydrargyri (gr. ii. or iii.) are given every night or every other night, or still smaller doses twice or thrice a day. None of these medicines can properly be employed without interruption for more than a few weeks : if their good effects are not perceived in that time, a perseverance in their use will hardly ensure them ; their use may, how- ever, be suspended for a week or a fortnight, and then advantageously resumed. The young prac- titioner should, however, very carefully endeavour to distinguish those cases in which an alterative plan of treatment affords any prospect of amend- ment, from those in which the loss of time in its ineffectual trial will prove injurious. The mind is prone to any belief which favours indolence; and there are practitioners who content them- selves with the delusion that no treatment, except the alterative treatment, is really efficacious in any chronic case. Another error, not very uncommon, is the pro- tracted employment of medicines of this sort. Their effects, not being suddenly produced, are sometimes overlooked ; or being brought about very gradually, and long expected in vain, they are at length watched for with less diligence, and disregarded when they might be discerned. The complete discontinuance of an alterative is of course best indicated by the desired improvement taking place in any case. When such medicines are properly applied, (and no medicine is useful but by timely application,) indications of their general effects, and even of their mode of action, may clearly be perceived. The tongue, for in- stance, loses its morbid coating ; the appetite im- proves ; the bowels become more regular; the skin grows smoother or freer from eruptions; the mind becomes more cheerful; the patient sleeps better; and the countenance becomes ex- pressive of that feeling of general comfort which is incompatible with chronic disease, and arises from the due and healthy performance of all the bodily functions. Unless some of these effects result from the use of alterative medicines, after a reasonable continuance, the practitioner should carefully inquire into the cause of such failure. He will probably find it in some local disorder, not to be removed without local treatment, and which he ought to have recognised at an earlier period. On the other hand, when the signs of amendment which have been mentioned appear, it should be recollected that to persevere in the use of alteratives is to apply to the body, in a state of health, actual causes of disease. It would seem superfluous to notice such plain and obvious particulars, if observation did not show us that, from the neglect of such plain and obvious things, o * lTIVES. 77 rather than of things less on the surface, mistakes are daily committed. With respect to the guaiacum, which has been enumerated among the alteratives, and which has a very ancient reputation, it is not easy to ascer- tain its precise share in the good effect produced by the compound calomel pill. Except in that formula, its application is nearly limited to certain cases of chronic rheumatism, in which, we fear, it must yet be allowed that Dr. Ferriar's observa- tion concerning it is correct; and that, whilst there certainly are some forms of the disorder in which its effects are excellent, it very frequently seems to have no effect at all. The tinctura guaiaci ammoniata, in doses of one or two drachms, is the most common form in which this medicine has been employed in rheumatic cases. We have ourselves little to say of its efficacy when used alone ; and we so often remark, when doubt has been once cast on the operation of a medicine, and the effect is carefully looked for, that it fails to be observed, as much to wish that not only the guaiacum, but many or most of the articles in the Materia Medica were submitted to new and careful clinical experiments. No part of medicine is in more need of complete reform than that which relates to the actual effect of medicines daily and hourly employed. The sassafras, like the guaiacum, is not often prescribed as an alterative by itself; it enters, with the mezereon, into the composition of the com- pound decoction of sarsaparilla, a medicine of great value in a very large class of cases. This decoction seems, in English practice, to have superseded the once famous Lisbon diet-drink, of which sarsaparilla and the sulphuret of antimony were among the principal ingredients. This is not one of the alteratives of which the good effects are to be expected from small doses. In- deed there is reason to think that disappointment has sometimes arisen from the decoction of sarsa- parilla having been given in too small a quantity. In ordinary cases, the patient is required to take a pint of the compound or of the simple decoc- tion daily; and three or five grains of the Plum- mer's pill, or three grains of the pilula hydrargyri, or five grains of the hydrargyrum cum creta, or a few grains of calomel and antimony, are common- ly prescribed to be taken at night during the use of it. But if it is desired to ensure the full effect of the decoction of sarsaparilla, and particularly if its operation is solely trusted to, the patient should be persuaded to drink two, three, or four pints a-day, and sometimes even a greater quan- tity. An alterative plan of treatment generally com- prehends the use of some of the medicines spoken of in this article. Others are occasionally em- ployed with the same intention, but it is unneces- sary to dwell upon them, for it will be seen that the line of division is, after all, rather artificial than real. Whatever medicines may be employ- ed with this indication, it should be remembered that the proper regulation of the patient's diet, and strict attention to all the articles of regimen, are indispensable auxiliaries ; the effects to be ex- pected from this kind of care being indeed obvi ously analogous to those of alteratives. 78 AMAUROSIS. vX [For alteratives, a term—as often used—con- veying no distinct meaning, Dr. Dunglison has substituted eutrophics, promoters of healthy nutrition. See Ectropuics.] j p0N0LLy AMAUROSIS, from apavpdw, to obscure. This , is the name applied to one of the diseases of the eye, in which defective vision depends on impair- ed sensibility of the retina. The term gutta serena has also been applied to this disease, from an erroneous notion that the dark enlarged pupil, J which sometimes accompanies it, is a drop of i black fluid which interrupts the passage of light. In practice, when a patient without opaque cornea, closed pupil, or cataract, complains of lost or defective vision, he is considered to suffer from this disease. Viewing the exquisitely delicate organization of the retina, and the origin, course, and compli- cated connexions of the optic nerve, it is not sur- prising that impaired vision should so frequently be produced by disease in some part of the nervous apparatus. The ultimate fibres of the optic nerve, expanded into a membrane of extreme tenuity, supported and disposed upon a membrane of nearly equal delicacy, from whence it derives its vascularity, and covered and separated from the neighbouring choroid by a tunic of still greater delicacy, present altogether a piece of anatomical organization most likely to have its functions im- paired by slight deviations from the natural or sound condition. Disorganization of the hya- loid membrane, upon which this delicate struc- ture rests, or of the choroid, with which it is ex- ternally in contact, may also materially affect its condition. The optic nerve, with its vascular and membranous accompaniments, enclosed in a sheath of fibrous membrane in its course through the orbit, pierced by the central artery, and close- ly connected with other arteries and nerves, is exposed to many injurious deviations from the natural structure. The same optic nerve within the head, from the vicinity of large vessels, and its complicated nervous connexions at the place of decussation, the tuber cinereum, the crura cerebri, the thalami, and the tubercula quadrige- mina, is liable to suffer from disorganization of its own structure, as well as of any of those parts with which it is connected. A review of the structure of the nerve of vision, from its origin at the tubercula quadrigemina to its anterior termi- nation at the ciliary processes, is the best pre- liminary exercise for one about to study the dis- ease of amaurosis. Injury or disease of the brain, as ruptured vessels, serous effusion, softening, tumor, or ab- scess, frequently impair the functions of the optic nerve, although such injury or disease should exist in a situation remote from the origin or course of the nerve. Amaurosis may, therefore, be a consequence of cerebral disease, although the optic nerve should be sound from its origin to its termination. [Lawrence on Diseases of the Eye, Amer. edit. p. 478 : Philad., 1843.] Injury or disease of a nerve, or morbid con- dition or irritation of particular organs, affect in- juriously the brain and nervous system, and thus impair the functions of the retina : hence amau- rosis from gastric, hepatic, or uterine disturbance. The experiments of Magendie, inconclusive as they are, and often proving too much for the hypothesis they are intended to strengthen, at least show that the fifth pair of nerves exerts some very important influence on the function of vision ; pathological observations on this subject, although few in number as yet, lead to the same conclusion, and the effects of injury of the frontal nerve in producing amaurosis, long since observed. establishes the fact. Ptosis, depending on disease of the third pair of nerves, is always accompanied by defective vision. Arterial and venous vascularity is an essential part of the organization of the retina, as it is of the whole nervous system; the existence of large vessels carrying red blood in a structure of such delicacy and transparency is even a remarkable circumstance, when contrasted with the apparently bloodless condition of many other white or trans- parent structures. Increased arterial action, or obstructed venous circulation, may, therefore, ma- terially affect the condition of the retina, and im- pair its sensibility. There is great variety in the perfection of vision in different individuals ; which may be attributed partly to a difference in sensibility of the retina, but in a still greater degree to a difference in pow- er of adaptation of the eye to distance. It ap- pears a great mistake to suppose that this differ- ence in perfection of vision depends altogether on the power of adaptation. A difference in perfec- tion of vision is often observed in persons who appear to enjoy an equally perfect power of adap- tation. A single lens remedies, in a great degree, the defect arising from want of power of adapta- tion ; but no single lens will confer on a landsman the distant vision of a sailor, nor on a long-sight- ed person the power of distinguishing minute ob- jects enjoyed by some near-sighted persons. It is scarcely reasonable to suppose that any altera- tion in curvature or relative positions of the cor- nea, or lens, in birds, can take place sufficient to account for the great superiority in vision which these animals enjoy. The sight of nocturnal ani- mals, and of persons who can see perfectly in obscurity, can only be attributed to a superior sen- sibility of the retina, as it is altogether independ- ent of any superior power of adaptation. The sensibility of the retina is increased by two totally different causes,—permanent exposure to a strong glare of reflected light, or a long-contin- ued residence in a darkened apartment. The inhabitants of snowy countries are obliged to adopt the precaution of protecting the eyes by means of a goggle, with a slit opposite the pupil* and the inhabitants of towns in which the build- ings are white are said to suffer from inflammatory affections of the eyes. Persons immured in dun- geons are said to acquire a power of distinguish- ing even small objects in their obscure abodes, in which, at first, they could not detect even a glim- mering of light. The morbid sensibility of the eye to light, in what is called scrofulous ophthal- mia, is in a great degree to be attributed to the injudicious exclusion of light from the eye by the use of shades, or confinement in a darkened room. The effect of light and shade upon the sensibility of the sound retina is beautifully exemplified by the simple experiment of directing the eye to AMAUROSIS. 73 Bome opaque object intervening between the ob- server and the light. If the eye be fixed for a few minutes upon the sash of a window, upon turning it in a different direction, a luminous im- age of the opaque sash remains. In this case the glare of light poured in through the glass on the unshaded part of the retina renders it less sensi- ble, while the part shaded by the opaque sash re- tains its original sensibility ; all the retina is after- wards exposed to the same quantity of light, yet to that part which was shaded it is a glare, while the part previously exposed to a stronger light has its sensibility blunted. If this explanation be correct, it is at variance with the fact previously stated, that exposure to the glare of reflected light, from snow or whitened buildings, raises the sensi- bility of the retina. The sensibility, however, produced by exposure in snowy countries appears to be morbid and permanent, probably connected with slight inflammatory action. That inflamma- tion of the eye is accompanied, in many cases, by morbid sensibility of the retina, is confirmed by daily observation ; and we have cases on record of persons being enabled to read, even in the dark- ness of night, in consequence of accidental injury producing inflammation. Amaurotic patients, suf- fering from inflammation, often observe an im- provement in vision while the inflammation con- tinues, which ceases as it subsides. These and many other facts and reasonings, which might be brought forward, prove that the retina in its most healthy and natural state is en- dowed with different degrees of sensibility under different circumstances, and, therefore, there can- not be any difficulty in admitting that morbid changes, however slight, may materially alter its functions. The facts stated, also, show that an acquaintance with the structure and functions of the retina must be the foundation of our know- ledge respecting the disease under discussion. The discussion of the causes of amaurosis in- volves so many details, and presents so many ap- parent contradictions, that some arrangement of the materials becomes absolutely necessary. A primary division into organic and functional has been suggested, and has been insisted upon by Mr. Travers in particular. This has been object- ed to, and justly, on the ground that, although we have abundant evidence of the occurrence of the organic disease, yet, that it remains to be prov- ed whether there is any disease purely functional, any disease which does not depend on structural or organic alteration, however temporary. For practical purposes we believe the distinction to be good. Daily observation proves that the func- tions of organs become instantaneously suspended, and as suddenly restored ; and this has repeatedly occurred in the case of the retina. By those writers who do not attempt any ar- rangement of this intricate subject, or who adopt an imperfect one, amaurosis is attributed to num- berless causes apparently directly opposite in na- ture : to inflammatory action and vascular tur- gescence from general plethora, or to debility from hemorrhage : to menorrhagia or to amenorrheca : to suppressed perspiration, healing of large ulcers or issues, sudden suppression of the secretion of milk, or to discharge from piles, nursing, diar- chcua, diabetes, ptyalism, or venereal indulgence : to the removal of cutaneous eruptions, or to the occurrence of gastric or intestinal irritation, exan- thematous diseases, dentition, or worms : to preg- nancy, or to total suspension or abolition of the uterine functions : to exposure to strong light, or to confinement in darkness : to drunkenness, nar- cotic poisons, direct rays of a hot sun, muscular efforts, grief, joy, fear, rage : to wounds or irrita- tion of nerves of the orbit, especially of the oph- thalmic branch of the fifth pair; to neuralgia, tooth-ach, or to total paralysis of those nerves : to hydrocephalus, hydrothorax, hereditary predis- position, hysteria, typhus fever : to metastasis of various diseases, as gout, rheumatism, and many others. If the primary division into organic and func- tional be good, it should afford us some clue to this labyrinth. The division, organic amaurosis, must obviously include those varieties of the dis- ease which depend on alteration in structure of the retina or of the optic nerve to its origin, em- bracing inflammation of the retina and its conse- quences, increased vascularity, thickening, or other alterations in texture, the organic disease by some described under the title glaucoma, fungus, hsema- todes, and hydrophthalmia. To this division must also be referred those cases depending on wasting, tumour, or other disorganization of the optic nerve, pressure from exostosis, aneurism, or other tumour. The functional form of the disease ne- cessarily includes those cases which depend on affections of the brain without actual diseased condition of the optic nerves, derangements of the vascular system, irritations of the gastric or intes- tinal mucous surfaces, disturbed uterine functions, mental emotions, and general debility. Hence amaurosis from hemorrhage, plethora, venous tur- gescence, menorrhagia, amenorrhoea, diarrhoea, worms, dentition, hysteria, venereal indulgence, suppressed cutaneous eruptions, nursing, and sup- pressed secretion of milk. Diseases of the brain present difficulties in the adaptation of this ar- rangement. Effusion of blood or serum, tumour or softening, may cause amaurosis, either by the effect on the sensorium generally, in which case the disease might be considered functional; or by actual pressure or destruction of the optic nerve in some place from its origin to its exit, in which case it is to be considered organic. If the example of some writers be followed, who consider amaurosis, from whatever causes it may arise, as presenting a certain uniformity of character, every symptom which has ever been found to occur in any form of the disease, must be enumerated as the symptom of that uniform disease. But it is obvious, that, although a cer- tain train of common symptoms present themselves in every form of the disease, amaurosis from pe culiar causes must afford peculiar symptoms. Thi symptoms common to the disease in all its varie ties, must first be enumerated, and those peculiar to each particular form detailed as such particulai form comes under consideration. Imperfection or loss of vision is, of course, the essential and prominent symptom of this disease; that is, the principal complaint of the patient, and the cause of his visiting the practitioner. The imperfection of vision varies both in degree and form. The student complains that he can no 80 AMAUROSIS. longer read with comfort, the letters become con- fused, indistinct, and run into each other; the mechanic complains that he can no longer follow his employment; the watchmaker can no longer detect minute flaws in his work ; the carpenter cannot make a correct joint; the smith no longer distinguishes the thread of a fine screw or the head of a rivet; and workers with the needle and at the loom become completely disabled from fol- lowing their employments. The next prominent symptom is the appearance of motes, films, gauze, cloud, or coils, intervening between the observer and the object, technically called muscse volitantes. These appearances are thus described, by Mr. Tra- vers, from personal experience : " The musca voli- tans is sometimes solitary, following the eye at a fixed angle as it passes along a line ; sometimes two, three, or more, are presented ; more frequent- ly an immense assemblage, descending in a cloud as the eye is raised, and ascending as it is depress- ed. They are obvious to so many analogies, and apprehension of impending blindness makes pa- tients so minute in their observation and descrip- tion of them, that it is scarcely possible to do jus- tice to our experience in attempting to describe them. Sometimes they are represented as globu- lar, sometimes angular and flat, like a piece of money. Portions of flue, of soot, insects' wings, transparent vesicles, or minute globules of quick- silver, connected like the links of a chain, or short hairs with their bulbs attached to them, are ordi- nary resemblances. They occupy the air with some persons, and are seen upon looking at the sky, or upon a white sheet of paper, and especially in shifting the eye from one object to another; to some they appear in the fire or candle only, and with others they seem to cover the ground, so that they walk in them knee-deep." [These ap- pearances may likewise be present when there is no serious affection of the eye. They are depend- ent upon some modification in the blood-vessels of the retina, which may never interfere farther with vision. (Dunglison's Human Physiology, 5th ed., i. 220 : Philad. : 1844.)] The next symptom of amaurosis is different in its nature from the last: the retina appears to be insensible in some of its parts, while the rest retains the natural sensibility to light. In such case the patient complains of double vision, or interrupted vision, as if portions of objects were deficient, as letters or syllables in words when reading ; or of half vision, when one-half of an object is seen distinctly and the other half is totally invisible ; or objects are seen only when placed in a par- ticular position, requiring some attention on the part of the patient to place the object in such a position as will direct its image to the sen- sible part of the retina. Ocular spectra con- stitute another symptom of amaurosis; in this case the images of luminous objects remain on the retina after the object has been removed, or the eye turned from it; as when the patient looks at the sun, a candle, or a patch of any bright colour, on turning the eyes away or even closing them, an image of those objects still presents itself, but of a different colour. The symptoms complained of by an amaurotic patient are thus summed up by Mr. Lawrence, in his published lectures : "The symptoms of amaurosis are such as are derived from the altered state of the function of the par^ and under this head you may have every kind of impaired vision ; every kind of defect in the per- ception of objects as to form, colour, and then relations to each other : the patient who has amaurosis generally complains of weakness or dimness of sight; he cannot employ the eye so long as he used to do ; the letters of a book begin to run into each other ; or other evidences of imperfect sight are noticed. In this early and incipient stage of the affection, where sight u only partially imperfect, it has been called ambly- opia amaurotica, amaurotic weakness of sight. The various defects of sight (vitia visus), enume- rated as distinct diseases in nosological catalogues, are only to be considered as amaurotic symptoms, forms of the impaired function. Of these may be mentioned, visus nebulosus, visus interruptut, visus dimidiatus, visus muscarurn, or myodesopia. Floating bodies appearing before the eye have been called muscae volitantes, and when only a single black speck is seen, it is called scotoma. It is not uncommon for a patient to see a black speck in the centre of an object; and as the affection proceeds, the opacity increases in size, becoming larger and larger, until it covers the field of vision. When these objects increase in number, they form before the eye a sort of gauze or network, and that state of vision has been called visus reticu- latus. Sometimes objects appear brighter than is natural, and that is called visus lucidus, or pho- topsia, and occasionally that brightness is so con- siderable as to produce uneasiness to the patient, which is then named photophobia. Isolated ob- jects are seen occasionally double, and hence the name sometimes given to amaurosis of visus duplicatus ; this, however, is generally the result of strabismus. There is also a visus coloratus and a visus defiguratus, from objects being seen of wrong shape and colours. In particular in- stances, the eye affected with amaurosis becomes near-sighted or far-sighted, or, as it is termed, myopic or presbyopic ; a presbyopic state of the eye is the most common attendant on amaurosis; it is less frequent for the eye to become myopic in this affection. It is very common for patients to be able to see objects laterally after they have lost the power of seeing them in the direct line of vision." The symptoms above enumerated are denomi- nated, by Mr. Mackenzie, the subjective symptoms, while he applies the term objective to those now to be noticed ; in other words, we learn from the patient the defects he experiences, and from obser- vation those which are visible to others. The state of the pupil, the action of the muscles of the eye, the attitude or expression of the patient, are of the latter description. The changes in organi- zation obvious to the eye must be distinctly con- sidered when amaurosis from this cause is dis- cussed. The size of the pupil, and the degree of activity in the motions of the iris, often afford valuable information as to the extent of disease, but, per- haps, not to be so far relied upon as is generally supposed. The motions of the iris, even if cor- rectly understood, are still the subject of dispute; and the complicated distribution and connexion ; of its nerves is not satisfactorily settled : it is AMAUROSIS. 81 therefore, not surprising that the state of the pupil in amaurosis should often be unintelligible. It cannot be denied that, in the majority of cases, defective vision from impaired sensibility of the retina is accompanied by a sluggish or inactive state of the pupil; and that, therefore, the state of the pupil must always be considered a valuable guide toward a correct knowledge of the cause and extent of the disease. In the commencement of the disease, the pupil dilates and contracts slug- gishly ; as the disease increases, the pupil becomes more dilated and fixed ; and in complete blindness it is fully and permanently dilated, constituting the true gutta serena. From this general rule, however, the practitioner finds many exceptions. Complete blindness is not necessarily accompanied by completely dilated pupil or gutta serena ; on the contrary, perhaps there are more cases of com- plete blindness with contracted or half-dilated pupils than with perfect dilatation. It is also to be remembered that complete and permanent dila- tation of the pupil is not necessarily accompanied by loss of vision : the application of belladonna proves that it is not; and cases of fully dilated pupils without blindness are occasionally met with. Amaurosis, both complete and partial, is some- times found to be accompanied by active and per- fect contraction and dilatation of the pupil. This is not the place to attempt an explanation of these apparent anomalies ; the subject is one of the greatest difficulty, and involves so many conside- rations foreign to the present article, that the stu- dent must be satisfied with the facts alone. The motions of the eye-ball and lids, and the general aspect, gesture, and bearing of the patient, often afford valuable information to the practi- tioner. Most writers have described the vacant expression of countenance which is often observed in persons completely blind from amaurosis. In such case the patient approaches with a moping stare and gesture of apprehension, as if completely bewildered. This is, however, often accompanied by other symptoms of paralysis, and is, perhaps, to be observed in those cases only which depend on cerebral disease. The gesture of the patient blind from cataract is different, because vision is not entirely gone; he approaches in an attitude as if endeavouring to see something through the thick cloud which is interposed between him and ob- jects. The motions of the eye-ball are often highly characteristic. The eye is either fixed, with very little mobility, or it turns irregularly in every direction, with a trembling oscillating mo- tion. This occurs most frequently in bad cases of long standing. Squint is another symptom often observed in amaurosis. This may arise from the effort of the patient to bring a more sensible portion of the retina into the position in which it may receive the impression of the image of the object; or it may arise from a diseased condition of the third or of the sixth pair of nerves. In the disease technically called ptosis, all the muscles supplied from the third pair of nerves are paralysed, and squint is produced by the action of the external straight muscle, which is supplied from the sixth pair. Squint is also unquestionably produced by paraly- sis of the external straight muscle from disease affecting the sixth nerve. Vol. I___11 [The method of examining the eye, termed the " catoptric," which consists in holding a candle before the eye, the pupil of which has been pre- viously dilated by belladonna, and noting the images of the candle, affords valuable information, where any difficulty exists, as is at times the case, whether the disease be amaurosis or cataract. When the humours are unimpaired, and the affection is wholly in the nerve of vision, three images of the candle are seen ; two erect, and one inverted ; the former reflected respectively from the cornea and the anterior layer of the crystalline ; the latter from the concave surface of the crystalline; whilst in cataract the erect, or the inverted image, or both, will be dull, indistinct, or absent, owing to opacity of the anterior or of the posterior portion the crystalline, or of both.] The origin, causes, and symptoms of amaurosis having been discussed in a general way, the dis- ease is now to be considered circumstantially in detail as it depends on distinct and obvious causes. The most frequent cause of amaurosis of the worst form is internal inflammation of the eye and its consequences. This is, therefore, the first to be considered. 1. Amaurosis from inflammation of the retina, and its conseq.uen ces. That amaurosis, or, to speak more plainly, defective vision, must attend inflammation of the retina is obvious ; it is, in fact, the symptom, not the disease : and, therefore, the subject of inflam- mation of the retina must receive distinct conside- ration. The first question to be settled is, whether inflammation of the retina ever exists perfectly insulated, and without involving the neighbouring structures ; or whether inflammation of the other parts of the globe of the eye, as the iris or choroid, ever occurs without involving the retina. This is a question of some difficulty. The functions of the retina are so frequently impaired from iritis, both during the existence of inflammation and after it subsides, that the extension of the inflam- mation from one to the other, or their co-existence in both, must be admitted ; and, therefore, the general adoption of the term iritis, and its frequent application to inflammation of all the contents of the eye-ball, have proved most injurious, by direct- ing the attention of the practitioner to the state of the iris exclusively, and placing out of view the retina, which, from its greater delicacy, and from its integrity being so much more essential to vision, should be an object of greater anxiety. It is not denied that iritis does occur without corre- sponding inflammation of the retina; but it is certain that they are both frequently engaged, and that the disease, in such cases, is general inflam- mation of the eye-ball, or internal ,ophthalmia. Mr. Travers says, in his Synopsis of Diseases of the Eye, page 137, that " the retina is some- times, though rarely, the seat of inflammation ; but it is an error to suppose that intolerance of light is a sign of this affection, as is clearly proved in the strumous ophthalmia, in which, though tho intolerance is in excess, the retina is uninjured : and, secondly, because the effect of inflammation upon a nerve of sense is to produce palsy, not increased excitability." That intolerance of light is not necessarily a symptom of inflamed retina may be admitted; but it is not proved that the 82 AMAUROSIS. effect of inflammation is to produce palsy of a nerve of sense. The causes of inflammation of the retina are as various as those of general inflammation of the eye-ball. The disease may arise from gout, rheumatism, syphilis, mercury, or typhus fever; or it may be idiopathic, without assignable cause. Mr. Lawrence appears to consider every form of amaurosis to arise from inflammation. He says, "Amaurosis, in its most frequent and important form, that which is seated in the eye itself, is generally inflammation of the nervous structure; including, under that phrase, all degrees of in- creased vascular activity, whether designated as fulness, turgescence, determination, congestion, or as inflammation in its most limited sense ; and the usual result of inflammatory disturbance, that is, organic change, permanently destroying the function of the part." Mr. Travers describes the symptoms of inflam- mation of the retina as follows : " the first and predominant symptom of inflamed retina, viz. a sudden attack of vehement dashing pain of the most distracting kind, which is described to extend from the bottom of the eye-ball to the occiput, or in the reverse direction, and the supervention within a few hours of total blindness, with occa- sional sparks and flashes of vivid light." " The pupil, upon inspection, is gaping and motionless, as in confirmed amaurosis, and the humours are thick and muddy." Mr. Wardrop observes, that, " When the retina is affected with inflammation, the disease is marked by painful vision; intole- rance of light; sparks of fire, or drops of a red colour falling before the eyes ; little external red- ness ; pain darting through the head ; with more or less constitutional derangement." To suppose that inflammation of the retina is always accom- panied by those violent symptoms would be dan- gerous in practice. The disease is often mild and insidious in its approaches, and marked more by defective vision than by symptoms of inflamma- tion. The first care of a practitioner, on approach- ing a person complaining of defective vision of recent occurrence, is, to ascertain whether there be any evidence of the existence of inflammatory action in the retina. The symptoms may often fail to satisfy him; there may be no pain, no morbid sensibility to light, no headach. The state of the pupil is no guide, as it is affec'.ed, more or less, in almost every form of amaurosis. The form or nature of the spectra, or muscx volitan- tes, does not enable him to pronounce with cer- tainty. The difficulty is, however, frequently removed by careful inspection of the state of the sclerotic coat. The arterial inflammatory vascu- larity of the sclerotic has always afforded a charac- teristic symptom of internal inflammation of the eye-ball, and has been dwelt upon with emphasis by Mr. Saunders, and subsequent writers. The red vessels converging toward the anterior part of the eye-ball, in distinct lines, and forming by their delicate subdivision irrto minute branches a bright red zone round the circumference of the cornea, is always pointed out to the student as an appear- ance indicative of internal inflammation, and a uniform accompaniment of iritis. This appear- ance often, perhaps always, in a greater or less degree, accompanies inflammation of the retina ; and when attended by defective vision and com- plaint of a film or gauze before the eye, should probably be considered conclusive evidence of the nature of the disease. The treatment of inflammation of the retina must embrace the means usually adopted to re- move or restrain inflammatory action, modified and proportioned to the nature, peculiarity, and intensity of the disease in each individual case. Such are, general bleeding, leeching, and cupping, nauseating and purgative medicines, mercury, and blisters. When the attack is accompanied by the intense and alarming symptoms just now enume- rated, on the authority of Mr. Travers, the adop- tion of a vigorous plan of depletion is obviously demanded, and general and local bleeding indi- cated ; recollecting, however, that we should not be too sanguine as to the result, or place too much confidence in these resources, unassisted by other means. Daily experience proves how un- availing mere depletion is found in irritis, or gene- ral internal inflammation, and even how unsuited to particular cases, however intense the symptoms. The value of mercury in the treatment of inter- nal inflammation of the eye in general, and of in- flammation of the iris in particular, is now so fully appreciated, that no argument need be employed to induce the practitioner to give it a fair conside- ration. Mr. Travers makes the following ob- servations respecting its administration : " When the amaurosis is recent and sudden, and either the signs of an obscure inflammation are present, or only the amplitude and inactivity of the pupil correspond to the patient's history, the indication is less simple ; mercury should be introduced with all convenient rapidity into the system, I mean so as to ruffle in the least possible degree. No ad- tagc is obtained by salivation ; on the contrary, I think it hurtful. When mercury is beneficial, its efficacy is perceived as soon as the mouth is sore. I have seen it tried, and have myself tried it in many cases of amaurosis, without the smallest ad- vantage ; but in cases of recent occurrence, im- perfect, but tapidly progressive from bad to worse, I have been witness to its power in suddenly ar- resting the disease in too many instances not to entertain a far higher opinion of it than of any other article of the Materia Medica." Mr. Law- rence, who, we have already said, appears to con- sider the majority of cases of amaurosis to arise from inflammatory action, sums up the treatment as follows : " Our object is to put a stop to vascu- lar excitement, to prevent the permanent injury of altered structure, and impaired function in a structure the peculiar delicacy of which particu- lirly exposes it to such danger. We must, there- fore, employ antiphlogistic treatment of a decided character, and follow it up with a decision and steadiness commensurate with the importance of the affected organ : under the head of antiphlo- gistic treatment, must he included general and local blood-letting, but more particularly the latter, as, by cupping from the back of the neck or the temples or by the appi-ation of leeches, the eva- cuation of the bowels by purgatives, and a re- stricted diet. Repose of the organ should be ob- served, more or less complete, according to the nature of the case ; counter-irritation by blisters, from which a discharge may be kept up by irri- AMAUROSIS. 83 fating dressing : these are the means suitable to the early stage of the affection, the stage of ex- citement ; but if this treatment be not found to remove the change which has been produced in the retina, we must have recourse to mercury, which appears to be as decidedly beneficial in these cases, as in iritis, or general internal inflamma- tion. The remark which I made respecting the use of mercury in those affections, applies also to the present case, namely, that its good effect mainly depends on the promptitude with which it is employed. The alterative form is insuffi- cient ; we give it with the view of arresting in- flammation in the structure, which is the very seat of vision : that structure is easily changed by the inflammatory process ; our only remedy is to push the mercury in a decided manner : and, if we do so, we shall put a stop to the affection. We have used mercury very freely for amaurosis ; we have used it until profuse salivation has been produced, and many decided instances of the good effect of this practice have come under our ob- servation." The practitioner has other resources than those above mentioned. Internal inflammation of the eye yields often to remedies of very different cha- racter ; and inflammation of the retina forms part of that disease. Cases may occur where general depletion is inadmissible. Old and debilitated females, scrofulous subjects, persons already weak- ened by disease, poverty, or confinement in ill- ventilated apartments, or who have, perhaps, just gone through a mercurial course, evidently would not derive relief from such treatment: on the con- trary, they would require a tonic plan of treatment, with the free administration of bark and generous diet If inflammation of the iris be arrested or restrained by the administration of turpentine, as stated by Mr. Hugh Carmichael, and it seems agreed that in certain cases, probably of peculiar character, it is a valuable remedy, it should con- stitute one of the resources in inflamed retina. Should the inflammation occur in a gouty or rheumatic habit, or alternate with affections of the joints, or other symptoms of these diseases, the treatment must be modified accordingly, and ad- vantage taken of the resources which medicine affords in such cases. Colchicum, under such circumstances, has been resorted to with some advantage. The eye should be protected from the irritation of strong light; but total darkness is unnecessary, and is probably pernicious, by in- creasing the sensibility of the retina. Care should be taken that, in excluding light, the free circula- tion of fresh air round the patient should not be interrupted. No circumstance has contributed more to the want of success in cases of this de- scription, than confinement of the patient to the respiration of an atmosphere contaminated by human clHuvia. 2. Amaurosis from oisoroanization of the retina, a conseq.uf.nce of inflammation. It is reasonable to believe, that during the in- flammation of the retina, vision is impaired by those changes which uniformly accompany in- flammation, as increased vascularity, and excited or altered sensibility ; while the effects or conse- quences, such as enlargement of vessels, and thickening or disorganization of structure, remain after inflammatory action has subsided. These two states present as remarkable a difference in j character as the acutely inflamed conjunctiva, and i the vascular and altered condition heretofore de- I nominated the chronic stage of that disease. In practice this distinction must never be lost sight , of, because the treatment of an inflamed retina j must be very different from that of a retina which i has formerly suffered from inflammation. The practitioner, therefore, has first to ascertain whe- ther the case before him be actual existing inflam- mation of the retina, or disorganization produced by inflammation. Cases of amaurosis from disorganization of the retina are of frequent occurrence, because this state of the eye is produced by every form of in- ternal inflammation. The patient complains of defective vision, under all circumstances : he can read with difficulty, for he can only distinguish the larger letters ; he sees the general outline of objects, or the more remarkable appearances in form or colour, but he cannot distinguish the fea- tures of those near him, or recognise his acquaint- ances. A film or mote of precise unvarying form appears to float before the eye, and frequently a uniform cloud or mist interrupts vision. A lighted candle appears as if seen through a mist, or is surrounded by a halo. These are a few of the symptoms of which the patient complains : many others of the same description are occasionally ob- served. On looking into the eye in such cases, the pupil may appear perfectly transparent; the iris may be capable of acting, though sluggishly ; and the cornea and sclerotic may be in an apparently healthy state. On a closer inspection, a slight irregularity of the pupil may be observed, which becomes more remarkable upon shading the eye from the light, and still more upon dilating the pupil with belladonna, when an adhesion of the margin of the pupil to the capsule of the lens at one or two points becomes visible. Where this little brown string of adhesion is attached to the capsule, a slight opacity of that part may be observed. This is the slightest de- gree of actual change of structure to be observed in those cases; in other examples the disorganiza- tion is much more obvious. If the eye has si - fered from severe internal inflammation, the entire margin of the pontracted pupil adheres ; causing a circle of white opacity at the place of adhesion, and leaving a central portion of the capsule and lens transparent, and capable of transmitting the rays of light to the retina. If the previous in- flammation has been still more destructive in its consequences, the pupil is much contracted, or even completely closed, and adhering to the cap- sule of the lens, which is opaque ; constituting capsular and, probably, lenticular cataract. The existence of the cataract does not alter the case as regards the retina ; it is still, partially or wholly, insensible to light, as is often proved by the want of success in operations for cataract in such cases ; and this very state of the eye should make the operator cautious in his prognosis as to the result of an operation, as in such cases the cataract may be removed, and yet no vision follow, on account of the disorganization of the retina. The sclerotic coat frequently presents, in such cases, a livid 84 AMAUKOSIS. vascularity, with large veins ramifying through it in every direction ; and in the worst cases the shape of the globe is altered, and the sclerotic is projected or stretched into a staphylomatous tu- mour, or depressed into hollows by the action of the muscles. This state of eye-ball is highly cha- racteristic of the completely unsound retina, and proves the hopeless nature of the disease. In considering the treatment of amaurosis, or impaired vision, the consequence of internal in- flammation, the first question to be determined is, whether the treatment adopted in the inflamma- tory stage be applicable to this : recollecting that the state of the eye now under consideration is a consequence observed many months, or even years, after the cause has subsided. The doubts re- specting the state of the retina, and the treatment of its diseases, arise from the impossibility of see- ing the alterations in its structure. Opacities of the cornea, and enlarged vessels of the conjunc- tiva, are visible after the inflammatory stage of purulent ophthalmia has passed away ; and the practitioner is, therefore, satisfied that he cannot remove them by a repetition of the depletion which he first adopted. If the thickness and vas- cularity, which probably exist in the retina, were equally visible, he would also despair of removing them by his first plan of treatment. Abstraction of blood may be advantageous in full plethoric habits, to relieve a turgid state of vessels already permanently enlarged ; but it should not be re- sorted to with the view of removing inflammatory action, which no longer exists. Mercury is fre- quently administered in these cases, and appa- rently because it has been found advantageous in the inflammatory stage. If mercury be of any use in such cases, it is by promoting absorption of lymph, or other deposit found during inflam- mation ; it is not, however, found to effect such objects in cases where deposits, or thickenings, are obvious to the eye, as in opacities of the cor- nea, or in closed pupil, and, therefore, probably possesses no such power here. At all events, mercury should not be indiscriminately resorted to, and a guarded prognosis of the result, of its administration should be made. To rouse the activity of the impaired function, or to raise the sensibility blunted by disorganization, impressions on the extremities of the fifth pair of nerves may be advantageously resorted to ; hence the practice of repeated blistering all round the orbit, or of applying stimulating liniments, or sinapisms, in the same situation. With the same view, ster- nutatories may assist; and perhaps, in certain cases, electricity. 3. Amaurosis fhom vascular timiges- cence, not amounting to inflammation. Amaurosis is sometimes caused by hemorrhage, as well as by a general plethoric state of the vas- cular system ; but it is difficult to determine why this happens in some cases only. Hemorrhage occurs every day, and yet blindness from this cause is rare. Amaurosis is not by any means a constant, perhaps not a frequent symptom of gen- eral plethora, or that state tormed a d'termina- tion of blood to the head. Whatever may be the condition of the arterial capillaries of the retina when the action of the heart is suspended, inter- rupted, or greatly weakened, blindness is not a necessary consequence ; it docs not occur in bleed- ing, unless faintness be produced ; it does not at- tend extreme weakness, with imperceptible pulse, preceding death ; nor is it a consequence of the application of a ligature on the carotid, which re- strains hemorrhage or cures aneurism. On the other hand, whatever may be the state of the ve- nous capillaries of the retina, during a turgid or obstructed state of the venous circulation, blind- ness is not found to be a consequence of tempo- rary pressure of the jugular veins, or of accumu- lation of blood in the right side of the heart, from disease of the heart or lungs. These considera- tions are important in a practical point of view; upon them the practitioner founds his estimation of the degree of value of a system of depletion, or the opposite plan of invigorating or increasing the activity of the vascular system. The first care of the practitioner in cases of de- fective vision, without apparent inflammation or disorganization of the retina, is to ascertain, as far as symptoms admit, whether there be reason to suspect increased arterial or obstructed venous vas- cularity. The amaurotic symptoms afford no sa- tisfactory evidence upon the subject. The informa- tion must be derived from the appearance of the patient, or the existence of undue vascular action elsewhere, turgidity of the vessels on the surface, especially those visible in the conjunctiva or scle- rotic, throbbing of the arteries of the head, or ful- ness of the jugular veins. Mr. Mackenzie, in his Treatise on the Diseases of the Eye, says, "It has been mentioned that plethoric persons are in general able to produce a degree of congestive amaurosis at will, by stooping, tying their neck- cloth tight, and the like. We also frequently wit- ness a temporary amaurosis from exhaustion. For instance, if the nervous system is the seat of no particular excitement at the time, we observe that by the sudden abstraction of blood, the organs of vision, and, indeed, all the organs of sense, are strikingly enfeebled. In some individuals the de- bility continues for several days, and if any one of the organs of sense has been previously weaker than the rest, the feebleness of that organ is gene- rally increased by bloodletting. When syncope is produced by loss of blood, sight appears to be the sense which fails first, and which recovers last Hearing is next, while smell, taste, and touch, are less affected, and more easily re-animated by exci- tation. They return in a very short time to their natural state ; but it is not so with sight. It is a popular opinion that bloodletting weakens the sight, and, to a certain length, the opinion is founded in fact." This view may be contrasted with that in the preceding paragraphs; but what- ever doubt may be entertained respecting the effect of particular states of the vascular system on vision, there can be none in practice as to the pro- priety of removing, if possible, a turgid state of the vessels, in persons suffering from amaurosis. If, therefore, a person complains of defective vision, with those symptoms which indicate vas- cular turgescente. the cause of this tumescence must, if possible, be ascertained. If the counte- nance is bloated and purple, and the conjunctiva full of large veins, and there are difficult respira- tion and other symptoms of disease of the heart or lungs, the cause is obvious. Such cases are of AMAUROSIS. 85 daily occurrence, and in the indications of treat- ment the removal of that cause must not be over- looked ; or, if it cannot be removed, the prognosis must be regulated accordingly. But if no such existing disease be obvious, and yet defective vision with symptoms of vascular turgescence be present, that symptom must be combated by the usual means ; as bloodletting local and general; blisters or sinapisms behind the ears as counter-irritants, or a seton in the neck, as a permanent discharge; sponging the forehead and head with cold water, using the shower-bath. The bowels should of course be emptied, and all future accumulation there prevented, and the functions of the stomach and liver preserved in a state of perfection. Ab- stemious diet, exercise in the open air, alterations in habits, and every other plan calculated to im- prove the general health, should of course be en- joined. In the application of this plan of treat- ment, the following observations of Mr. Travers deserve attention : " A loss of balance in the sanguiferous system, occasioning an undue deter- mination of blood to the head, often exists distinct from general plethora, and is aggravated by loss of blood. Cases of undue determination of blood to the organ are especially common after deep- seated chronic inflammation, or distress from over excitement, by which vessels have lost their tone; an effect decidedly increased by depletion." 4. Amaurosis from interruption of the functions of the digestive organs. Whatever doubts may be entertained respecting the efficacy of the treatment of amaurosis by eme- tics and purgatives, it appears to be agreed on all hands that defective vision is often a consequence of interruption of the functions of the digestive organs. That amaurosis is, however, every day attributed to this morbid condition where there is no evidence of the existence of any such cause, is known to every practitioner; but it is equally notorious that it is frequently a symptom of dys- pepsia, and its occurrence from worms or other irritating matters in the alimentary canal is a still more decisive proof of the effect of such causes. It must not be forgotten, that in the majority of these cases the individual is exposed to those remote causes which may lead to the interruption of the functions of the retina as well as those of the alimentary canal. The sufferers are generally artisans or students, whose gastric organs may be injured by their sedentary habits, mental exertions, or confinement in close and unhealthy apartments; while vision may at the same time be impaired by the application of the eye to minute or brilliant objects. For practical purposes, it is only neces- sary to determine whether a patient complaining of impaired vision, and muscse volitantes, with sluggishly acting or fixed pupil, foul tongue, head- ach, flatulence or acidity of the stomach, and tor- pid bowels, should be treated for his dyspeptic symptoms, or only for the amaurosis ; and, on the other hand, whether a patient complaining of im- paired vision, muscse volitantes or spectra, and presenting a fixed or inactive pupil, without any apparent symptom of gastric disease, should be treated with medicine calculated to remove dyspep- sia. Whatever doubt may be entertained respect- ing the propriety of the administration of emetics and purgatives in amaurosis, where the state of the digestive organs does not indicate it, there cannot reasonably be any in directing the atten- tion to this object where defective vision is accom- panied by gastric derangement. Schmucker and Richter in Germany, and Scar- pa in Italy, have been the most decided advocates for the emetic practice; and in this country it has been followed up with various degrees of success : upon the whole, however, the testimony of writers is unfavourable to the practice, at least unless in- dicated by symptoms of gastric or biliary derange- ment. The following is the plan adopted by Scarpa : " The first part of the treatment of im- perfect amaurosis is restricted to emetics and in- ternal resolvents. It is desirable in the majority of cases, if the patient is an adult, to prescribe three grains of tartar emetic dissolved in four ounces of water, of which he should take two spoonfulls every half hour until nausea and abun- dant vomiting be produced. The day after, he should take the resolvent powders, composed of an ounce of cream of tartar, and a grain of tartar emetic, divided into six equal parts. The patient should take one in the morning, another four hours after, and a third in the evening, for eight or ten days in succession. This remedy will cause some nausea, and produce some more frequent discharge of the bowels, and perhaps some vomiting. If during the employment of these resolvent pow- ders the patient makes ineffectual efforts to vomit, if there is a bitter taste in the mouth with loss of appetite, without any improvement in vision, the emetic should be repeated ; and this for three or four times, if the presence of gastric irritation, hitter taste in the mouth, tension of the hypochon- dria, acid eructations, and tendency to vomit de- mand it. When the stomach is cleared out, the resolvent powders of Schmucker should be pre- scribed, consisting of the following ingredients : Gum. sagapen., Galban. Sap. venet. aa. gi; Rhei. giss ; Antim. et Potass. Tart. gr. xvi. Ext. gly- cyrr. gi; Ft. pil. gran, unius. Fifteen of those pills to be taken night and morning for four or six j weeks; or the formula of Richter, consisting of the following ingredients, may be preferred : Am- moniac. Assafmtid. Sap. Venet. Valerianae rad. Summit, arnicas aa. jjii; Antim. et Potass. Tart. gr. xviii. ft. pil. gr. 2. Fifteen to be taken three times a day for some weeks." It is scarcely ne- cessary to observe that the farrago composing these resolvent pills can possess no peculiar virtue, and that modern improvements place more valuable remedies and resources in the hands of the prac- titioner. Nor need we repeat here the plans of treatment to be adopted for the removal of the dis- eased condition of the stomach or alimentary canal. The educated practitioner must suit his treatment to the peculiarities of each particular case ; keep- ing in view the necessity of removing all offend- ing matters from the stomach and bowels, avoiding all food or drink calculated to aggravate the dis- ease, and altering as far as possible the habits of the patient. It is desirable to record the opinions of practical writers respecting the treatment just alluded to. Mr. Travers, p. 304, says, " I do not recollect an instance of decided benefit from the emetic prac- tice, although, in respect to its high authority, I have tried it fairly in many instances. The cases 86 AMAUI of gastric disorder to which it is especially appli-1 cable, are most benefited by a long course of blue I pill, with gentle saline purgatives and tonic bit- J ters. In most of those cases we must depend, first, on the regulation of the visceral functions; j and, secondly, on the employment of such resto- ratives as the system requires and can bear. The blue pill, with colocynth, rhubarb, or aloes, and the combination of soda with rhubarb and Colombo or gentian, are best adapted to the former purpose. The exhibition of general tonics is often strongly I indicated, and I have seen much benefit derived from the mineral acids, bark, steel, (when admissi- ble,) and arsenic, after a due regulation of the j digestive functions. I know of no article of the class of stimulants that has any direct claim to ' notice, or any approach to a specific virtue, such as has been ascribed to the arnica montana, aco- nite, &c." Mr. Lawrence, who, as has been : already observed, considers the majority of cases j of amaurosis to depend on inflammatory action, or vascular turgescence, observes, " When the antiphlogistic treatment and a fair trial of mercury have failed, I do not know that it is possible to effect any further essential good by other means. We must be contented with such management and simple diet as are most conducive to general health, and take the chance of such local amend- ment as the affected organ may slowly experience under gradual general improvement. Residence in a pure air, frequent exercise out of doors, a plain, mild, but nutritious diet, the regular use of mild aperients, with the occasional employment of a more active purgative, and repose of the affected organ, form a combination of measures best calcu- lated to invigorate the system generally, and thus, as far as circumstances will admit, to arrest local disease. The effects of counter-irritation may be advantageously tried in conjunction with such measures. Blisters may be applied behind the ears, and at the side or back of the neck, and a discharge may be kept up by the savin cerate. But we prefer a succession of blisters, applying a new one to a fresh surface every five, six, or seven days." [The endermic use of strychnia has been advised by Mr. Middlemore, (Treatise on Diseases of the Eye, p. 290,) and by Messrs. Liston, Henderson, Furnari, Petrequin and others; but Mr. Tyrrel and Mr. Lawrence, (On Diseases of the Eye, Amer. edit., p. 519,) have never seen it or veratria exert any power over the disease. It has been used, also, internally, and in the form of collyrium, containing .from two to eight grains to two ounces of water; a little acetic acid being added to render the strychnia more soluble; and two drops being let fall into the eye a few times a day. (Dunglison's New Remedies, 4th edition, p. 554, Philadelphia, 1843.) Besides blisters, acupuncture, moxas, ammonia- ted lotions, and every form of revellent, have been j used to the temples, behind the ears, or to the back of the neck. Some cases of imperfect amau- rosis have likewise been treated with success by j galvano-puncture ; and similar results have been | obtained from the use of a galvanic current, made to pass from the mastoid process to the superci- liary ridge, (Op. clt., p. 40 and p. 327.)] | tosis. 5. Amaurosis from exercise of the ets ox minute objects. It cannot be denied that defective vision is occasionally produced by exposure to this cause; but when it is recollected that thousands, nay millions, are thus exposed, in a greater or less degree, some doubt may be permitted as to its operation, especially when sufferers in this way are exposed to other causes which affect the health generally. Students, scriveners, printers, engra- vers, microscopic observers, watchmakeis, gilders, furnace-workers, and cooks, are enumerated among the sufferers from this cause. But there are seden- tary or unhealthy employments calculated to im- pair the functions of many organs, and in this way alone to produce that state of the retina which accompanies the disease. Simply using the eyes constantly in intently viewing minute objects, although such objects should not reflect any unusual quantity of light, appears to impair vision as much as working on brilliant objects; at least we find as many cases of impaired vision among tailors, scriveners, shoe-makers, and cabi- net-makers, as among engravers, gilders, glass- blowers, or cooks. The question which it is here important to solve, is, what is the state of the retina in these cases ? Is it a state of excitement with morbid sensibility and increased vascular action, a state approaching to inflammation } or is it the very reverse, a state of impaired sensi- bility and defective vitality ? Until these questions are solved, impaired vision, from these causes, cannot be positively referred to the division of functional amaurosis more correctly than to the organic. It has already been stated that Mr. Lawrence considers amaurosis of this character to depend upon inflammatory action, or, " vas- cular activity, whether designated as fulness, turgescence, determination, congestion, or as in- flammation in its most limited sense." The symptoms, in cases of this description, are merely impaired vision, disabling the patient from following the usual pursuits of reading or work- ing ; muscae volitantes, or spectra, of various colours, forms, and qualities, floating before the eyes ; and a fixed or sluggishly acting pupil. It does not appear that the symptoms are materially different, whether the disease has arisen from exercise of the eye on brilliant objects, or on objects merely minute. Whether it may be advisable to rely upon a treatment directed to the improvement of the func- tions of the digestive organs in amaurosis, from these causes, must be very questionable. The principal reliance must be placed in the removal of the original remote cause. The patient should understand that no remedies can avail while he continues to exercise the eye as before. There can seldom be much difficulty in accomplishing these objects, when the patient does not depend for a livelihood upon the exercise of his eye; but the poor artisan has often only the alternative between starvation and blindness. Under such circumstances, every argument should be used to induce the patient to give up his trade for a sum- mer, and to endeavour to earn his bread by rural occupations. The most careful inquiry and ex- amination must be made to ascertain whethei AMAUROSIS. 87 there be any evidence of the existence of inflam- ] matory action or vascular turgescence in the retina. The history and progress of the case, the I appearance of the sclerotic and pupil, the consti- tution and habits of the patient, must be the best guides. The practitioner could not reasonably determine to adopt an antiphlogistic treatment | with a sallow, pallid, emaciated patient, whose eyes present no unusual vascularity ; while it ' might be imperiously demanded in a bloated, gross man of intemperate habits, and whose eyes are disfigured by vascularity. If it be necessary to adopt the antiphlogistic plan, it is to be followed up as detailed when speaking of inflammation of the retina, and recourse had to the administration of mercury to the same extent. If the digestive organs are impaired in function, they must be im- proved by the usual means. If there is no evi- dence of inflammatory action, but, on the con- trary, a languid circulation and general debility, every method calculated to improve the general health must be adopted, as pure air, invigorating diet, and tonic, medicines. Blistering and other stimulating applications in the vicinity of the orbit, and pungent applications to the nostrils, and even to the conjunctiva itself, may be found of service. 6. Amaurosis from injur* or disease of the fifth nerve, or its branches. It has long been known that injury of the frontal nerve, or branch of the ophthalmic branch of the fifth, is injurious to vision, and, conse- quently, that this nerve exerts some very im- portant influence on this function. Little more than this is now known, notwithstanding the attempts of Magendie to clear up the doubts on the subject by experiments on animals. These experiments, which are detailed in his journal of physiology, are of so violent and destructive a nature, and so much calculated to disturb or destroy the functions of the nervous system gen- erally, that the Tesults stated to have followed can- not be attributed to the mere division of the fifth nerve. It is, however, most probable, since vision is impaired by injury of a branch of the fifth nerve, that it should also be impaired or destroyed by division of its trunk. Pathological observa- tions, hitherto not numerous or authentic, will probably do much more toward elucidating this subject than destructive experiments on living animals. No opportunity should be lost of as- certaining the state of vision previous to death, in persons whose fifth nerve shall be found dis- eased or destroyed. The nature of the connexion between the fifth nerve and the nerve of vision is illustrated by the fact, that, in cases of conjunc- tival inflammation, modified by scrofula, violent sneezing is produced by exposure of the eye to light. Disease or growth of a tooth has some- times been found to impair vision. Such a case is recorded by Dr. Galenzouski, of Wilna, m the Archives Generates, where blindness was pro- duced by a splinter of wood becoming entangled in a diseased tooth. Mr. Travers, says, « I have seen an incipient amaurosis distinctly arrested by the extraction of a diseased tooth, when the <,elay of a similar operation had occasioned gutta serei.a, on the opposite side, two years before. Defec- tive vision frequently attends neuralgia in the vicinity of the eye. Mr. Travers, says, » There is an intermittent spasmodic pain accompanying some cases of amaurosis, shooting through the orbit into the head, of the most acute and dis- tressing severity ; it makes a periodic attack at or about the same hour every night, and continues for several hours ; it is accompanied by convul- sive quivering of the muscles of the eye and eye- lids, and profuse lacrymation ; there is nothing in the appearance of the organ to explain its nature and origin. What has been described as an in- termitting ophthalmia, is, I think, improperly so termed__the pain, not the inflammation, is inter- mitting. The pain of tooth-ach, according to the state of the vascular system, is subject to inter- missions more or less complete ; but the periodic pain to which I refer, is independent of any visi- ble sign of inflammation. I believe it is a tic douloureux, affecting one or more of the orbitar branches of the fifth pair of nerves. I have cured it, in two cases, by arsenic, where opium failed to prevent the paroxysm. I have known one in- stance of a similar affection, without any defect of vision." Mr. Wardrop affords the following information on this subject: " Wounds of the eye-brow, injuring the frontal nerve, have fre- quently been known to produce amaurosis ; the amaurotic symptoms coming on in some cases instantaneously, and sometimes long after the wound has been healed." Morgagni mentions having seen a case of amaurosis produced by a wound above the eye-brow, which, he observes, explains a passage of Hippocrates. " The sight," says the lather of medicine, "is obscured in wounds which are inflicted on the eye-brow, or a little higher." This curious fact we have seen illustrated in several instances; and it is an example of the sympathy which exists between parts whose nerves have a direct communication, the ophthal- mic branch of the fifth pair sending off the fron- tal nerve, and also a twig to join the third pair to form the lenticular ganglion. It is only when the frontal nerve is wounded or injured, and not divided, that amaurosis takes place; for, as will hereafter be observed, amaurosis, following a wound of this nerve, may sometimes be cured by making a complete division of the trunk nearest its origin. Portal saw a child, who received a slight juncture on the forehead with the point of a knife, which was followed by a considerable con- vulsion of the upper lid. This ceased when a small incision was made at the place of the punc- ture. A gentleman received an oblique cut in the forehead, which, from its direction and depth, must have injured the frontal nerve. The wound was not accompanied by any severe symptoms, and soon healed. But afterwards the vision of this eye began to fail, and in a few months was completely destroyed ; the pupil was much dilated, the iris was not influenced by variations of light, and had slight tremulous motions. A sailor got a blow on the edge of the orbit, from a ramrod during an engagement, at the place where the frontal nerve passes on the brow. The vision of that eye was instantly destroyed, and when we saw him several years after the accident, the eye remained amaurotic, with a dilated and immovable pupil : a cataract had formed in the other eye. An officer, at the siege of Badajos, received a 88 AMAUROSIS. deep wound on the eye-brow by a piece of a shell, which, from its direction, must have injured the frontal nerve. Great inflammation and pain suc- ceeded the wound, the vision of the eye became gradually imperfect, and, after a few months, was entirely lost. The pupil was very much dilated and immovable, and the crystalline lens opaque. Wounds of the infraorbitary nerve and portio dura are sometimes followed by amaurotic symp- toms. Beer mentions an instance of the former; and we witnessed the case of an officer, in whom a ball wounded some branches of the latter nerve, which was followed by amaurosis. This con- nexion between the branches of the fifth pair of nerves and retina affords a useful channel for ap- plying remedies in diseases of retina. It is not injury of the fifth pair of nerves alone that proves injurious to vision ; paralysis of the upper lid, with loss of power of moving the eye-ball, except outward, evidently depending on compression or disease of the third pair, is also attended by defec- tive vision. The writer of this has very recently seen a well-marked case of amaurosis with dis- tinct and undoubted paralysis of the abductor muscle, disabling the patient from turning the eye outward, and obviously depending upon compres- sion or disease of the sixth pair of nerves. To cure amaurosis from injury of the frontal nerve, or any other branch of the fifth pair, is difficult, and often not to be accomplished. Divi- sion of the nerve appears an obvious resource, and has been repeatedly tried, but with little success : which, perhaps, might have been anticipated, when it had been observed that amaurosis had sometimes arisen from simple division, as in the removal of a tumor. Mr. Guthrie, says, « The only hope of relief that we are at present acquainted with, lies in a free incision made down to the bone, in the direction of the original wound ; and even of the efficacy of this, I am sorry I cannot offer testi- mony from my own practice, having failed in every case in which I tried it." Some of these cases recover, or at least improve, by time ; a re- sult to be expected, when it is recollected that the numbness from division of a branch of a nerve often disappears. The general health, in such cases, should be attended to ; all pressure on the wounded part avoided, and gentle frictions, with a liniment containing belladonna, tried, especially if there be pain. The occurrence of blindness from injury of a branch of the fifth pair is instructive, because, as Mr. Wardrop observes, it throws light upon a question of importance in the treatment of amau- rosis, the efficacy of superficial impressions in rousing the sensibility of an amaurotic retina. Some appear to undervalue, or even discard the use of stimulating applications to the vicinity of the eye in cases of amaurosis, such as blisters, sternutatories, liniments, rubefacients, sinapisms, or pungent applications to the conjunctiva itself: but when we see violent sneezing produced by the impression of light, and recollect the other proofs of connexion of function between the nerves here, we are more than justified in giving trial to such means. [In some cases, amaurosis has yielded to the extraction of one of the teeth of the upper jaw, of the same side as the affected eye; doubtless through the impression made directly on rami- fications of the fifth pair, and indirectly on the retina.] 7. Amaurosis from injury of the Eyb. Blindness is generally the consequence of a violent blow on the eye-ball, although none of the visible parts of the organ appear materially injured. What the real extent of the injury in these cases may be, is not certain ; but it is very probable that the delicate connexions of the retina with the neighbouring structures arc injured or severed; or there may be ecchymosis of its structure, or in the cells of the hyaloid membrane. Vision, in such cases, is greatly impaired, or even totally lost; and the pupil is generally irregular in shape and dilated. If the accident be followed by in- flammatory action, the usual appearances of inter- nal inflammation of the eye-hall are added. The prognosis, in these cases, must be very cautious ; because the prospect of recovery depends upon the extent of the injury, which cannot be ascer- tained. If vision begins to improve some hours, or even days, after the accident, which is often the case, further improvement may be anticipated. In such cases it may, perhaps, be suspected, that there has been more of concussion than actual destructive disorganization, and, therefore, gradual recovery may be expected. Even if the improve- ment in vision be still slower, but progressive, perfect cure will probably follow. But if vision be greatly impaired or destroyed, with irregular and dilated pupil, and without any amendment after some weeks, the worst may be apprehended. When the injury, which is often the case, extends to the iris or lens, and terminates in cataract, other considerations, foreign to the present inquiry, sug- gest themselves. The first care of the practitioner, in cases of this description, is to avert or allay inflammation, by cold applications to the eye, local and general bleeding, purgative medicine, and abstemious diet. The inflammation sometimes assumes a chronic character, proceeding to disorganization of the eye, as rheumatic inflammation does, and cannot be arrested by the usual means. Whether, in such cases, recourse should be had to mercury, is a doubtful question ; but experience does not en- courage the practice. In this chronic state of the disease, blistering is indicated, and may be resort- ed to with advantage. Under any circumstances, after all inflammation, or danger of inflammation, has subsided, efforts should be made to rouse the sensibility of the retina by external impressions. The means of effecting this object, which are ap- plicable to this case, as well as to every other of loss of sensibility of the retina, without inflam- matory action, are, blisters, sternutatories, pungent applications to the conjunctiva, and electricity; all which may be tried without injury, and with some hope of success. The conjunctiva may be conveniently stimulated by the fumes of ammonia, or by the vapour of ether evaporated from the palm of the hand, as suggested by Mr. Ware. It has already been stated that amaurosis is caused by various diseases or habits, affecting the nervous and vascular systems generally. Such diseases or habits are either debilitating, as hemor- rhage and menorrhagia, diarrhoea, venereal indul- gence, suckling; or they are calculated to accele- AMENORRHCEA. 89 rate vascular action, and produce a general ple- thoric condition, as suppression of accustomed discharges, drunkenness, and gluttony. Metasta- sis of diseases, as of gout or rheumatism, or the removal of cutaneous eruptions, may often be found a cause of amaurosis. Diseases affecting the optic nerve by pressure, or involving it in some specific disorganization, as aneurism, exos- tosis, tumours of various kinds, fungus haematodes, cancer, and caries of bones of the skull, necessa- rily produce imperfection or destruction of the functions of the retina. Diseases within the head, as rupture of vessels, ill-balanced circulation, soft- ening, hydrocephalus, enlargement of arteries, and tumours, are some of the most frequent causes of amaurosis. General disturbance of the functions of the nervous system, not depending on disease of the brain, as hysteria, and those affections known under the common term nervous diseases, are often accompanied by amaurotic symptoms. In all these cases the origin of the defective vision is obvious to the practitioner, and the nature of the origin suggests the treatment. The amauroris, in many of them, is merely the symptom, which disappears upon the removal of the remote dis- ease. The history and treatment of amaurosis depending on the causes just now enumerated, are not, therefore, detailed here. , T Arthur Jacob. "^ AMENORRHEA. Amenorrhoea has been usually divided into retention and suppression of the menses. Under this head we shall also con- sider vicarious menstruation. I. Emansio, or retensiox of the Menses. The non-appearance of the menstrual discharge at the usual age does not, in itself, constitute a disease. The condition of the bodily develope- ment must chiefly be taken into consideration, for the age at which the ovarian functions are first manifested varies exceedingly. Instances of very precocious puberty are numerous ; neither is it at all uncommon to meet with cases where the men- strual discharge does not occur till a very late period of life : but if the general health is not affected, medical interference will be rarely requir- ed. Climate has a marked influence over the period of puberty. Whilst in sultry regions sex- ual maturity will usually take place at the age of eight or ten years, in colder countries it is deferred till eighteen or twenty ; and in Lapland, accord- ing to Linnams, women will often menstruate only during the summer months. [Mr. Roberton (Edinb. Med. and Surg. Jour- nal, Oct. 1832, and Lond. Med. Gazette, July 21, 1843,) has endeavoured to show, that the age of puberty is as tardy in the colder as in the tropical regions, and that were marriages to take place in England at as juvenile an age as they do in Hin- dostan, instances of very early fecundity would be as common in England as they are in that country. He is of opinion, that early marriage and early intercourse between the sexes, where found prevailing generally, are to be attributed not to any peculiar precocity, but to moral and politi- cal degradation, exhibited in bad laws and customs, the enslavement more or less of the women, igno- rance of letters, and impure or debasing systems of religion. He has also shown from statistical evidence, that menstruation does not occur more Vol. I___12 * * early in the negress than in the white female. (Dunglison's Human Physiology, 5th edit., ii. 348. Philada., 1844.)] In temperate climates, the usual period of pu- berty is about fourteen years of age ; and when the signs are delayed much beyond that age, or when the sexual developement takes place, but is not followed by the consequent monthly discharge, amenorrhoea may be said to exist in the form we are now describing. The two conditions of body are, however, essentially different. In the former, puberty itself is delayed, whether from idiosyn- crasy, from want of constitutional energy, or from defective organization. In the latter, puberty ex- ists ; the ovaria and the uterus are organically matured ; but their peculiar function is suspended. In the former condition, we meet with young women of eighteen or twenty years resembling children in conformation, with a weak and lan- guid frame, a feeble circulation, attenuated, colour- less, and of stinted growth. The case is obviously one of constitutional debility, and, only as such, requires medical treatment. Should the general powers be renovated by time, or the judicious employment of tonics, a nourishing diet, salubri- ous air, and well regulated exercise, the menstrual discharge will either take place with other signs of puberty, or the case will become of the descrip- tion above alluded to, and presently to be noticed. But puberty may also be delayed with another condition of body, where the general health and strength continue unimpaired, the growth proceeds as rapidly as in others, the circulation is active, and the frame vigorous ; but there are no protu- berant mammse, no sexual propensities, a slight beard grows on the upper lip, and the general characteristics resemble those of a male. In such a case the probabilities are that the ovaries are either absent, or have become so diseased that their functions are entirely lost. A striking in- stance is related by Mr. Pott, where a precisely similar state was artificially induced by removal of the ovaries in a young woman in St. Bartholo- mew's Hospital, although, previously to the ope- ration, menstruation and all the signs of puberty had regularly existed. In such organic defects medicine is of no avail; though, under the possi- bility of the ovarian functions being interfered with by the pressure of some neighbouring tu- mour, the use of iodine, potass, mercury, or other medicines to promote absorption, might be advis- able. When, at the usual age of puberty, a decided change in the system is observed, and a struggle is evidently taking place to bring about the sexual functions, although followed by no actual devel- opement, we may conclude that the defect is only in degree, and that, by proper assistance, nature will accomplish her object. In some cases, the failure may be said to be merely local : the mam- ma? are enlarged, the pelvis has become capacious, the pudenda covered with hair, puberty is estab- lished, but the menstrual discharge does not take place. There are now peculiar symptoms set up; head-ach, with a sensation of fulness and throb- bing, a flushed countenance, heaviness, pains in the back and limbs, and a full pulse, generally remarkably slow, though, in some cases, accele- rated. There appears to be either a torpor of the 90 AMENORRHEA. uterine vessels, which ought to secrete the men- strual discharge, or (as some have supposed) a spasm of their extremities. The causes of this condition are generally to be found in the previ- ous habits of the patient; for it is most frequently met with in those who have led sedentary and indolent lives, who have indulged in luxurious and gross diet, and been accustomed to hot rooms, soft beds, and too much sleep. The ramedies are usually successful, and rapidly so. In the first place, the overloaded circulation is to be relieved by a brisk purgative, abstemious diet, and the ab- straction of blood ; if the symptoms of plethora are strongly marked, bleeding from the arm in considerable quantity may be required ; but, in general, the application of leeches to the labia, pubes, groins, or os uteri, or cupping on the loins, will be sufficient. Bleeding from the foot, either by leeches or from a vein, was formerly preferred ; and many practitioners of the present day still recommend it, as equally salutary and more pala- table to the patient. The purgatives most effica- cious in such cases are those which not only un- load the vessels, but stimulate the rectum : aloes, colocynth, or senna and the neutral salts, are pre- ferable ; and, in addition to these plans, pediluvia, either of simple hot water, or made stimulating by the addition of mustard-flour, may be used for half-an-hour, night and morning. This treatment should be persevered in till the symptoms of ple- thora disappear, when it may be suspended, and merely a free action of the bowels kept up by the daily use of an aloetic purgative, either till the menstrual discharge comes on, or till, at the end of about a month, the congestive symptoms again are perceived, to be again similarly treated. Ex- ercise, especially on horseback, will materially assist in promoting the desired effect, and, of course, all the old habits of self-indulgence are to be entirely broken through. Should these plans fail, we must have recourse to those remedial agents which have been supposed more particularly to have the property of exciting uterine torpor, and which we shall notice in considering the next description of cases. In these, as puberty approaches, there is a marked derangement of the general health, from the powers being unequal to the impending strug- gle. The patient has been, perhaps, growing rapidly, and has perceptibly become much emaci- ated ; the face and lips are pallid; the hands and feet cold, particularly the latter; there is great lassitude, and the least exertion produces fatigue ; the tongue is foul, the bowels are costive, the appetite is defective and irregular, the pulse slow and feeble. A more aggravated set of symptoms gradually supervenes; the complexion becomes peculiarly sallow, often of a greenish tint; and hence the name frequently given to this stage of the disease, green sickness, or chlorosis : (see Chlorosis.) Every part of the system partakes of the general torpor ; the circulation becomes ] still more languid; and the blood seems, as it were, to stagnate in the veins. The digestion is nearly gone, the tongue covered with a dirty coat, and indented, at the edges, by the teeth; the breath is fetid, and there are frequent acid or offensive eructations, with air rumbling in the bowels, which are generally obstinately confined ; ! and when they are acted upon by medicine, the motions are dark and foul. The appetite is irre- gular and capricious ; so that the most indigestible substances are oflen craved and devoured with greediness ; chalk, slate-pencils, sealing-wax, tal- low, and dirt; for it is by no means true that the longing is always for articles which nature points out as" salutary, as, for instance, anti-acids and absorbents. The spirits are weak and depressed ; hysterical tears are easily excited ; the girl pre- fers a moping solitude ; and decided melancholy, with delusions, will occasionally be manifested. The absorbents partake of the general debility; and there will be puffiness of the face after sleep, and anasarcous extremities in the evening. Pal- pitation of the heart will be frequently trouble- some, and there will be dyspnoea on the slightest exertion; and along with this latter symptom, a short distressing cough. Hence it is that there is no disease more frequently mistaken for phthisis, and the error is a most serious one ; for much injury would be occasioned by the remedies gene- rally administered for the latter complaint. The causes of this disease may be shortty stated, as all those which depress the vital powers, viz. a previously delicate and unhealthy childhood, in- sufficient or improper food, want of pure air and exercise, too close a confinement to study in schools, or to labour in crowded manufactories, the de- pressing passions, and, in particular, according to many, hope deferred, and disappointed sexual feelings. In treating the disease, the amenorrhoea must at first be considered as only one of the train of symptoms of disorder of the general health. It is advisable to begin with an active purgative, which will often bring away a large collection of highly offensive motions, with manifest relief to the pa- tient. Small doses of blue pill may be afterwards occasionally repeated, and purgatives of a warm and stimulating character taken every morning, combined with a small quantity of some bitter extract or infusion, until the tongue appears cleaner, and the secretions from the bowels are more healthy. A more decided tonic of the vege- table class, along with myrrh, rhubarb or aloes, and ammonia, will gradually prepare the stomach for the metallic tonics, and above all others for that medicine most useful in these cases, namely iron, which, in one form or another, may be nearly always taken with benefit in a torpid condition of the venous system. Upon the whole, perhaps, the Griffith's mixture (rnistura ferri composita of the Pharmacopoeia) is the most serviceable of the artificial preparations of iron. At the same time the bowels must be kept fairly opened with the above-mentioned purgatives, those containing aloes being preferable. The diet must be, at first, light and easily digestible ; and, as the stomach is pre- pared for an improved and more nourishing food, wine, meat, and eggs may be taken. Gentle exer- cise in a carriage or on horseback, particularly the latter, with sea-bathing or the shower-bath, may be ventured upon cautiously as the strength im- proves. A pure air is very desirable, and on that account, when the patient has a little advanced, nothing is more efficacious than a residence at Tunbridge-Wdls, or some other places where chalybeate springs abound, combining the advan- AMENORRHCEA. 91 tages of change of scene, a salubrious atmosphere, amusement to the mind, and the internal use of the mineral water. With returning health and strength, the func- tions of health may be expected, and, amongst them, the menstruation ; but it often happens that in this particular respect we are disappointed, and we now come to the trial of those remedies which have been found by experience to act either directly or indirectly in promoting menstruation. For the more complete consideration of this class of medicines, we refer to the article Emmena- gosues. It will be sufficient here to mention those which are considered most serviceable at the present day. Some act by stimulating the neighbouring parts, the rectum and the bladder; such are the more drastic purgatives, aloes and melampodium ; ene- mata of soap or turpentine; tincture of Spanish fly ; savine, turpentine, and some of the balsams, internally. A combination of myrrh, aloes, sul- phate of iron, and the essential oil of savine, has been fou*id frequently of great utility by the writer of this article. Warm hip-bathing, hot and stimu- lating pediluvia, warm frictions to the hypogastric and lumbar regions, electricity or galvanism ap- plied to the pelvis, have by many been proved beneficial; and it is often of great service to com- bine with one or other of these plans, the appli- cation of leeches to the groins, labia, or os uteri, or to the feet, once a month. Compression of the crural arteries by the tourniquet was formerly much in vogue, by which a larger quantity of blood was thrown upon the uterus. Irritation of the os uteri itself by means of bougies has been proposed, or the injection of a stimulating lotion into the upper part of the vagina, which has suc- ceeded in a considerable number of cases; for this purpose a solution often drops of liquor ammoniae in an ounce of milk has been advised once or twice in the twenty-four hours, and on several occasions the effect has been very rapid. Of supposed direct emmenagogues, the madder and spignel, formerly so much vaunted, have now fallen into disrepute. The only medicines of modern days, which can at all lay claim to that character, are iodine and the ergot of rye. Dr. Coindet, of Geneva, considers the former the most powerful and certain emmenagogue we possess, and attributes its success in bronchocele to the sympathy which the uterus and the thyroid gland manifest for each other. The ergot has been extensively used in various conditions of the ute- rus, and certainly seems to exert peculiar and powerful action on that organ, which may, per- haps, deserve the name of specific. In the cases before us, it may be tried in the form of decoction, infusion, or powder. The writer has given it frequently, and, in many instances, successfully, in doses of ten grains and upwards, three times a day. In very irritable habits it must be cautiously administered, as it has been found after a few days to produce sometimes violent and even highly dangerous spasmodic effects. [Dr. Churchill (Diseases of Females,- includ- ing those of Pregnancy and Childbed,' Amer. ed?t., p. 65 : Philad., 1843,) thinks that the medi- cines, of whose power of acting on the uterus there is the least doubt, arc iodine, ergot and strychnia ; yet it may be questioned whether these, or any agents, have an effect which adapts them for all cases, and merits for them the title of emmena- gogues. (See Emmenagooues.) Dr. Ferguson, indeed, (Library of Practical Medicine, 2d Amer. edit., iii. 302,) classes these and other agents under the title of "nostrums;" and the truth would seem to be that there is, in the existing state of knowledge, no remedy that acts specially upon the uterus, so as to restore the menstrual discharge when obstructed. They are all indi- rect agents; and, inasmuch as amenorrhoea may be dependent upon opposite pathological condi- tions, the remedies have to vary accordingly. (Dunglison's Practice of Medicine, 2d edit., ii. 392 ; Philad., 1844.)] There is one circumstance to be kept in mind in the management of these cases. The menstrual discharge may be secreted regularly, but there may be no exit, the passage being closed by an imperforate hymen, or an obliteration of the va- gina, either from original malformation or from disease. In these cases, in addition to the periodi- cal recurrence of the symptoms of menstruation, there is a gradual enlargement of the abdomen from the retained fluid collected in the uterus, so that unjust suspicions of pregnancy are apt to be raised. A manual examination at once detects the impediment, and it is easily removed by a surgical operation. [The obstacle may exist at the external opening : at other times, a membrane covers the os uteri, or the canal of the cervix may be imperforate. In the last case, Dr. Churchill proposes to make an artificial canal, by means of a trocar, or an instrument resembling that used by Stafford for dividing strictures of the urethra ; but it need scarcely be said, that such an operation should be decided upon and executed with exceed- ing caution. Where a membrane over the os uteri is the obstacle, it may be punctured or rup- tured, and a probe or small bougie may be passed into the uterus, as described under Dysmenor- rhea. (Practice of Medicine, loc. cit.)] II. Suppression of the menses. Suppression of the menses may take place at any time after menstruation has been once fairly established, and may be either acute or chronic; in the latter case it is most commonly the effect of disorder of the general health, although by females it is apt to be considered as the cause. Acute suppression generally arises from some cause acting immediately previous to or during the menstrual period; such as an attack of fever, exposure to cold or wet, anxiety of mind, frights, or any agitation of a depressing character, a meal of improper or indigestible food, &c. A few years ago, a very interesting case was communi- cated by Dr. Burrows to the Medico-Chirurgical Society, of acute suppression ending in mania and catalepsy, which was occasioned by sexual inter- course, under very exciting circumstances, during menstruation. Some have argued that in these cases the amenorrhcea is merely the effect of fever excited in the system, and that the secretion from the uterus is checked, as all other secretions are in fever. But this idea is not always correct; for often, during menstruation, the sudden appli- cation of cold or wet will stop the discharge, long before the existence of fever, and without any 92 AMENORRHOEA —ANEMIA subsequent fever at all. In such instances, if the patient puts her feet into warm water, gets into a hot bed, and takes some diaphoretic drink or medicine, the discharge will return in a few hours. But in many cases the acute suppression is pre- ceded or accompanied by general fever, quick pulse, hot and dry skin, coated tongue, a flushed countenance, violent head-ach, throbbing of the temples, and pain in the back and limbs. In habits at all plethoric, abstraction of blood is desirable ; an emetic, followed by an active saline purgative, may be also given ; a warm bath, hot fomentations to the abdomen, and diaphoretic medicines, combined with opium, will then be found of the greatest service ; and if, after we have reduced the immediate symptoms, the men- struation is still suspended, we may consider it a case of chronic suppression. Chronic suppression of the menses is either the consequence of a previously acute attack, or is the result of impaired health. In the latter case it often comes on slowly, the menstrual discharge either becoming gradually more and more scanty, or the intervals between the periods being more and more protracted, till at last there is a total suppression. In either of these cases there is much the same train of symptoms as described in the history of retention of the menses ; but there is almost always much more head-ach and pain in the loins. The causes are also similar, and the treatment varies only according to the peculiar derangement of health which produces or accom- panies the suppression. It would be useless to repeat the details, and it will be only necessary to state, that, here even, the discharge may be ob- structed by a closure of the vagina from ulceration after a difficult labour, or as the effect of irritating discharges. The possibility of pregnancy should also be kept carefully in view, as the cause of the suppression ; and this caution is even applicable to cases of retention of the menses, for a previous menstruation is not absolutely necessary for con- ception, but only that condition of the sexual organs which is directly preparatory to menstrua- tion. Sir Everard Home has stated a case where menstruation occurred for the first time in life, after the birth of more than one child, the second pregnancy taking place during lactation. Professor Frank has related a still more remarkable instance, of a patient who bore three successive children, and never menstruated at all, either previously or subsequently. Vicarious menstruation. The consideration of this curious freak of nature is most appropriate to the history of amenorrhoea, because it does not occur except when menstrua- tion is checked. It appears to depend principally upon a torpid or amenorrhoeal condition of the uterus ; and the periodical evacuation being pre- vented, either by accidental causes immediately before the expected period, or by a previous indis- position, a larger quantity of circulating fluid is thrown back upon the system, and forces a pas- sage for itself at some distant part. It also usually seems necessary that the vicarious outlet should be already in a weak, irritable, or disordered con- dition. Accounts are given of this periodical discharge of blood taking place from the lungs, the nostrils, the stomach, or the bowels; and these are not uncommon cases. But instances have also occurred where the flow has been from the bladder, the nipples, the umbilicus, the eyes, the ears, the sockets of the teeth, the skin generally, and also from open ulcers in various parts of the body. It is the practice of some to bleed in these cases, to diminish arterial action ; but it does harm, except in very plethoric constitutions, when leeches to the labia, groins, or os uteri, a day before the expected period, would be much more beneficial. The object to be gained, is not only to control and prevent the hemorrhage from the particular part by the proper remedies, but also to rouse the torpid uterus into action. In the inter- vals of the attacks, metallic tonics, and especially iron, should be freely given, combined with myrrh and aloes ; and some of the more direct emmena- gogue plans may be tried immediately before the expected period. Opium has proved of great ser- vice in many of these cases, combined according to the peculiar condition of the health, and the character of the part morbidly in action. Thus it may be given in conjunction with the* mineral acids, or the superacetate of lead, a few days before the expected hemorrhage from the lungs; or in combination with the subnitrate of bismuth, where the stomach has been the vicarious outlet [In all cases it is important to inquire into the cause of the aberration, both as regards the system in general, and the uterus in particular; and, moreover, to attend to the condition of the part whence the vicarous discharge proceeds. It has been properly remarked, that the state of the organ probably assists in determining the discharge to it; hence, vicarious haemoptysis is, perhaps, of more consequence than any other form ; and partly, also, because there is danger—even if the dis- charge should be a mere transudation of blood through the parietes of tolerably healthy containing vessels, that a predisposition may be left to some other pulmonary affection.] ~, T [AMYGDALITIS. See Throat, (Diseases OF THE).] ^/AN^EMIA. This term is derived from a, pri- vative, and aipa, blood, and means, therefore, a deficient quantity of the circulating fluid, or blood- lessness. The haematosis, or formation of the blood, is begun in the stomach and completed in the lungs. A morbid state of any one of the organs or func- tions which concur to effect the hsematosis may lead to a state of anaemia. It is in this manner that we have a defective state or quantity of the blood in some forms of dyspepsia, especially chlo- rosis. It is in this manner, too, that the workers in certain coal-mines have, from a deficiency in the pulmonary function, been struck with anaemia. A similar state of anaemia has also arisen from disease in some particular organ forming a part of the class of those which contribute to the hsema- tosis ; a case, the exact seat of which is often ob- scure. It is scarcely necessary to add, that a state of anaemia is also the immediate result of losses of blood either artificially or by natural hemor- rhage. These are precisely the cases to which the term anaemia has been variously and too indiscri- minately applied. M. Andral describes anaemia at great length, and has distinguished different forms ANEMIA. 93 of local anaemia, or anaemia of the individual organs. The case of chlorosis, to which the term anae- mia has been applied adjectively, will be treated of distinctly in this work. So will the case of anaemia from actual loss of blood. In the present article we purpose to describe, 1. that form of anaemia which has occurred in coal-mines ; and, 2. that other form of the disease which has an obscure origin in the morbid condition of some organ contributing to the haematosis : 3. to these will be added the view taken of anaemia by M. Andral, and especially the case of local or topical ansemia. General anaemia is denoted by extreme paleness, especially of those parts which, being covered by the thinnest and most transparent investing mem- brane, ex pose the condition of the blood underneath them, as the prolabia, the tongue, the gums, the internal surface of the cheeks, &c. The face, the hands, and the general surface are pallid, and slightly waxen or icterode in their hue. There are vertigo, faintishness, palpitation, and an im- paired action of the organs generally, especially of the stomach and bowels, digestion being de- ranged, with flatulency, constipation, &c. I. The following description of the anaemia of the coal-miners of Anzain is translated from an account given by M. Chomel, in the article Ane- mie, of tbe Dictionnaire de Medecine : " All the workmen employed in one of the gal- leries of the coal-mines of Anzain fell sick in the summer of the year 11, although that gallery had been wrought for some time. The workmen of the adjoining galleries escaped, although the only observable difference was that they were less ex- tensive, and the ventilation less difficult. The disease began with violent colic, with tympanitic distension, black and green alvine evacuations, to which were added dyspnoea, palpitations and great debility. These symptoms subsided in the course of twelve days, and then those of anaemia ap- peared : the face assumed the colour of wax ren- dered yellowish by time ; the blood-vessels had so entirely disappeared that not a trace of them could be found where they are usually most obvious, as in the conjunctiva, eye-lid, internal mouth; the arterial pulsations were feeble; these appearances continued even during attacks of fever, which came on accidentally in some of the patients : ex- treme feebleness; great anxiety ; slight oedema of the face ; palpitations ; shortness of the breath on the slightest effort; perspirations ;—such were the symptoms : although the appetite was not lost, yet the digestion was imperfect, and there was a progressive loss of flesh. "This state continued during six months or a year, sometimes terminating in death, preceded by the symptoms which first appeared. The Nuciete de 1'Ecole de Medecine was consulted. Four patients were conveyed to Paris, and placed under the care of M. Halle. A nutritious diet, infusion of hops and gentian, the "w antiscor- butique," were conjoined with mercurial frictions. During this treatment one patient died ; on exa- mination, the arteries and veins were found desti- tute of coloured blood, and containing only a little serous fluid ; incisions through the muscles gave rise to no flow of blood, except a little from those of the thigh. The absence of blood, which was in accordance with the external phenomena, led to the disuse of mercury, and to the substitution of the internal use of iron (limaille porphyrisee,) in the dose of a " gros" daily, under the form of opiate, with tonics. In eight or ten days there was an evident amendment: several veins appeared under the skin of the fore-arm ; the digestion improved ; the shortness of breath diminished. On each suc- cessive day the patients pointed out, as discoveries, new veins, which had not been perceived the day before. The amendment was progressive, and quite complete when these men returned home. " Similar morbid appearances were observed in some of the patients who died at Anzain. And the same mode of treatment proved successful both there and at Dunkerque, whither some of the sufferers had also been conveyed." The want of sun and the want of air seem to have been the causes of this singular malady. These important agents appear to be essential to the haematosis. [See Air, change of.] The effects of the want of blood are illustrated in an interesting manner. But the consideration of this point is reserved for a distinct article. II. The origin of the second form of anaemia is more obscure. We shall illustrate the subject by an abstract of a case published by Dr. Combe, in the Transactions of the Medico-Chirurgical Society of Edinburgh. Dr. Combe first visited his patient in July, 1821. He looked like a man recovering from syncope : the symptoms were pallor, languor, breathing easily hurried, pulse 80 and feeble, tongue covered with a dry fur; the bowels relaxed, the stools dark and fetid ; thirst, want of appetite, rejection of food; no pain; no detectible organic disease. The patient was forty-seven, married, of regular habits, and engaged, first in agriculture, and then as a servant to a corn-merchant; he was never blooded. These symptoms had stolen upon him during two months; he said his head troubled him ; and the feet were oedematous. Some tonic medicine, a mild nutritious diet, and wine were prescribed. Afterwards iron, mercury, opiates, and astringents were given. Towards the end of September, he tried a sea-voyage, and a chalybe- ate spring. He died in January, with all the symptoms of hydrothorax. On examination, not a drop of blood flowed on dividing the scalp ; the dura mater was moist, and displayed few vessels, and those empty; near the vertex, to the left, there was an ossification ; the pia mater was pale, its blood-vessels containing a pale serum, and air; a slight effusion under the arachnoid. The brain was soft and pulfaceous, with few vessels, and little difference of colour between the cineritious and medullary portions; the ventricles contained two drachms of serum ; and about two ounces were found at the basis. The lateral sinuses were moderately filled with pale fluid blood ; the arte- ries at the basis were empty. In the thorax there were three pounds of a lemon-coloured serum ; the lungs were of a pale grey, without any mark of gravitated blood. The pericardium contained an ounce of serum. The heart was pale; the right ventricle contained a pale coagulum ; the left was empty. The inner coat of the aorta was of a fine red colour. There was some moisture 94 ANAEMIA. in the abdomen ; the liver was of a light brown colour ; the spleen alone was of its natural colour, and soft. The arteries were universally empty, as were the jugular and femoral veins; the lower cava alone contained any blood. The whole case, and, indeed the whole subject, is exceedingly obscure. It does not appear that any examination of the thoracic duct was made, which is much to be regretted. III. We now proceed to notice the different forms of local anaemia; and, in doing so, we shall chiefly draw upon the recent work of M. Andral. (Precis oTAnatomie Pathologique, p. 73.) M. Andral traces the cases of local ansemia, 1. to a diminution of the principal artery; 2. to cer- tain affections of the nervous system; for instance, may not the stomach become ansemious like the cheek ? 3. to the hyperaemia of other organs; 4. to a previous state of hyperaemia in the organs affected with anaemia; 5. lastly, without being able to trace it to any of these causes, a state of anaemia is sometimes seen in some particular organ. M. Andral adds that he has observed this state of anaemia particularly in the brain, the heart, the liver, the stomach, and some other parts of the ali- mentary canal, and some of the voluntary muscles. With a state of ansemia of an organ, that of atrophy is sometimes conjoined. With anaemia of the membranes, we often ob- serve an augmentation of their secretions; this is seen in the serous and mucous membranes, and in cutaneous textures. When anaemia is induced in an organ by the sudden obliteration of its principal artery, as by ligature, gangrene is the result. M. Andral concludes this subject by the impor- tant remark, that the symptoms of the anaemia of an internal organ'are sometimes observed during life : convulsions and delirium arise from anaemia, as well as hyperaemia, of the brain. Similar states of the stomach may lead to their peculiar symptoms respectively. It is, indeed, quite plain that the state of anae- mia, of which the actual loss of blood is one of the most frequent forms, leads to phenomena which require to be carefully distinguished and appropriately treated. For the fuller discussion of this important subject, we refer our readers to the article Blood. ,, TT Marshall Hall. [Anemia is generally applied to that condition of the system in which there is paucity of blood : more properly it might be termed Hi/pacmia, or Oligasmia. It likewise includes that condition in which the watery portions of the blood predomi- nate largely ; or what has been called Hydrosemia, or Hydrxmia. When blood is drawn from a patient affected with general anaemia, it is found to possess a smaller proporlion of crassamentum, and this is loosely cohering : the quantity of serum, on the other hand, is greatly augmented. The essential character of the blood of the anaemic is the oppo- site to that of the plethoric—paucity of globules. In 16 cases of incipient anaemia, M. Andral (Hxmatologie Pathologique, Paris, 1843,) found the proportion to be 109 in place of 127, the healthy proportion ; and in 24 cases of confirmed anaemia, 65. In spontaneous anaemia, slight or considerable, he found the globules, alone, dimm- ished in quantity : the fibrin and solid matters of the serum possessed the healthy proportion. In the anaemia that follows hemorrhage, the glo- bules, alone, may have their proportion dimin- ished, but if the hemorrhage should augment, or be renewed, the blood soon begins to lose some of its other principles, and, along with the globules, the fibrin and the albumen of the serum diminish. In ansemia induced by inappreciable modifications of the organism, the composition of the blood was affected as in spontaneous hemorrhage : thus, the globules alone were found to be diminished, the fibrin and albumen of the serum remaining the same. This was the case in several pregnant females, whose blood had lost globules without any diminution of its fibrin. Andral found the mean proportion of globules in them the same as in cases of slight anaemia. Owing to the proportion of fibrin to the red globules being increased, the buffy coat is not an uncommon phenomenon in anaemia, and especially in chlorotic cachexia (see Chlokosis); for it appears that whenever there is an increase in the proportion of fibrin to the red globules, and, at the same time, the coagulation of the blood is not too rapid, the fibrin accumulates at the sutface of the blood, and the buff appears. Whenever a certain diminution takes place in the proportion of the globules, a bellows' sound is heard on auscultating over the arteries. According to M. Andral, this is connected with the impove- rishment of the globules, inasmuch as it is not heard when the fibrin alone is diminished in quan- tity. The same sounds are heard as in chlorosis (q. v.). Chlorosis, indeed, belongs to anaemia; and amenorrhoea is not unfrequently accompanied by the same anaemic condition. The different functional phenomena, which are characteristic of anaemia, generally occur in a gra- dual manner, and it is long before they induce so much disease as to cause death. In the very thin state of the blood that accompanies it, hemorrhage readily occurs from parts in which the vessels are but loosely protected by the tissues in which they creep,—as from the mucous membranes,—the gas- trointestinal especially,—and these hemorrhages greatly hasten the fatal termination, both by the increased exhaustion which they induce, and by their laying the foundation for hydropic, or other mischief. On the dissection of those who have died of anaemia, the tissues have been found pale, and the vessels and heart almost exanguious. The heart, too, is often atrophied, and its tissue softened and flabby, especially if the disease has been of long duration. The intestinal canal is frequently also pale, and the serous cavities and cellular membrane are infiltrated with serous fluid. In the treatment, it is all important to inquire into the pathological cause, and to remove it, where practicable. In almost all cases, it is essen- tial to put the patient on nourishing diet, and especially where the anaemia has been caused by imperfect nourishment; yet care must be taken in the very impressible condition of the system which exists in these cases, that undue excitement be not induced. The respiration of pure air is likewise all important. ANASARCA. 95 The best therapeutical agents are, the prepara- tions of iron,—the iodide, subcarhonate, citrate, lac- trate or tartrate, for example. The iodide, in the writer's experience, is the best form. Dr. C. J. B. Williams, (Principles of Medicine, Amer. edit., by Dr. Clymer, p. 143, Philad., 1844,) considers it to be most speedily efficacious, ft not unfre- quently, however, disagrees, and it becomes neces- sary to substitute one of the other preparations. The different mineral and vegetable tonics may be given, but they have less efficacy. To relieve the nervous erethism that always exists to a greater or less degree, the hydrocyanic acid is well adapted; and a full dose of opium will often allay the ex- cessive vascular and nervous tumult that sometimes prevails. Under careful management, with the observance of the strictest mental and corporeal quietude, the blood may gradually become im- proved in its constitution, and the phenomena of anaemia gradually disappear. (Practice of Medi- cine, 2d edit., p. 456, Philad. 1844.) Robley Dunglison. *^A N.ESTHESIA. See Paralysis.] ANASARCA: from avct, through, and strangulo) having been ap- plied by the ancients to all diseases of the throat accompanied by a feeling of suffocation or stran- gulation. (Celsus, lib. iv. cap. iv.) The word is still used in this sense by the French, Germans, and other continental nations, comprehending all the inflammatory affections of the fauces, larynx, trachea, and neighbouring parts, classed by Dr. Cullen under the head Cynanche. It is evident from the expressions above quoted from Dr. Heber- den, that he adopted the name in common use, qualifying its new application by the addition of the word pectoris. It is, therefore, incorrectly said by Dr. Frank, that this name has nothing in common with the same word as applied to affec- tions of the th.roat.j- This author derives the term from the Latin verb angere, taking this in its more general or metaphorical sense, as signify- ing to occasion distress, and apparently forgetting that this word is itself derived from ay^u. and, in strictness of language, means the same thing. As the word angina has ceased to be applied, in the medical language of this country, to inflammatory affections of the throat, we shall adopt its use in the present article without always retaining its qualifying adjunct pectoris. Angina can boast of a very copious synonymy. The following are the principal names by which it has been designated by different writers, and the order of their imposition : — Cardiogmus cordis sinistri..........Sauvaees, 1763 Angina Pectoris...................Heberden, 17G8 Die Brustbriiune....................Eisner, Diaphragmatic gout................Butter, Asthma Arlhriticiyii ...............Schmidt, Syncope Angens...................Parry, Asthma Dolorificum................Darwin, Slernodynia Syncopalis.............Sluis, Asthma tpastico-arthritjeum incon-) gtoener stans.........................i Suspirium cardiacum...............Stephen, Sternalgia.........................Baumes, Stenocardia........................Brera, Pnigophobia.......................Swediaur, 1812 Angor Pectoris.....................Frank, 1818 [Neuralgia of the heart.............Hope, 1832J Although the above catalogue does not go far- ther back than the time of Sauvages, there can be no doubt that the complaint was well known to practical men from the earliest periods of physic ; but like several other affections now classed under particular names, and regarded as distinct dis- eases, it was merely considered as a symptom, or isolated group of the ordinary symptoms, or as an accidental complication or particular phasis of some known disease; and, if noticed at all, passed under the usual name. Before the time of Dr. Heberden, indeed, Sauvages, after Poterius, cer- tainly noticed and named the affection as a sepa- rate form of disease; but of this fact Dr. Heber- den was ignorant; and his much fuller and more 1780 1791 1795 1799 1801 1802 1803 1804 1K)6 1^10 * Some Account of a Disorder of the Breast. Read at the College, July 21, 17t#. Medical Trans, vol. n. p. 59. t Hoc vocanuliim nihil commune habet cum eo anginas, sub quo faucium inflammatio vulgo intelligitur. Pras. Med. Univ. P. ii- vol. viii. p. 244. 104 ANGINA'PECTORIS. accurate history justly entitles him to the honours of an original observer. Many passages in the writings of the ancients, and particularly in those of Hippocrates, might, without much straining, be made to apply to this disease, notwithstanding the round assertion of the last named author, that " the heart is a dense and solid body, and there- fore unsusceptible of pain."* Some have imagined that Aretaeus referred to angina under the name of irvtvfiibiec; but his account is much less charac- teristic of the affection than many passages in the writings of Hippocrates. The account which Aretaeus gives of the second species of angina comes much nearer the disease which we have to describe under the same name. (Aretaci Opera, p. 7. Oxon. 1723.) In the works of Caelius Aurelianus, a brief statement occurs in his chap- ter on paralysis, which has been generally con- sidered, and apparently with reason, as referring to the disease now under consideration.! The case of Seneca, as described by himself, has also been generally considered as a case of angina, and we think most justly. He terms his disease sus- pirium. (Senecas Opera, t. ii. p. 136. Epist liv.) In perusing the medical writings of the sixteenth and seventeenth century, we meet with many observations which can only apply to this disease. These are most commonly found in their account of asthma, with which, as a well-known disease, and as having some of the external symptoms somewhat similar, it was most likely to be con- founded. It was with this disease, or at least with dyspnoea, that it was confounded by Poterius and Barteletti, certainly the first medical writers who notice the disease in such terms as cannot be mis- taken4 In the works of Hoffmann and Mor- gagni, many well-marked cases of angina will be found.§ One of the earliest, probably, and cer- tainly one of the most unequivocal cases of angina to be found in the English language, is that of the father of the great Lord Clarendon, recorded by his son. In this case the event was fatal.|) After the publication of Dr. Heberden's paper, the disease was noticed by a vast number of medi- cal writers in England, France, Germany, and Italy, both in periodical publications, in the trans- actions of societies, and in distinct treatises. Since it first attracted attention, angina seems, indeed, to have been a favourite with the profession, and the mere catalogue of the published cases and mono- graphs would fill many pages. The reader who is curious in this matter is referred to the writings * Est cor res solida ac densa, et propterea dolore non affligitur. De Morb. lib. iv. cap. x. f Erasistratus memorat paralyseos genus et paradoxon appellat, quo ambulantes repente sistuntur ut ambulare non possint, et turn rursum ambulare sinuntur. Chron. lib. ii. c. i. p. 348. I Qutedam est respirandi difficultas (says Poterius) quie per intervalla deambulantibus accidit. In liac fit pneceps virium lapsus, propinquis tenentur niti adiiiinj. nulis, alias humi corruerent; hi ut plurimum derepente moriuntur. Pet. Porter. Op Oin.cum Annot. Hoffmann. p. 302. Franco/, ad Man. 1IS98. Fabricius Barteletti, in his Methodus in Dyspnaam, {Bonon. I»i32) speaks (if a variety of this affection, ■'quee in ambulations motu erumpens sola quiete mitescit." § A single case selected from the works of each of these authors suffices to prove that they were well acquainted with the disease. See Hoffmann. Consult. Med. Cas. 83. Op. t. iv. p. 125. Mergagni de Sed. et Caus. Morb. lib. ii. epist. xxvi. art. 31. ll Life of Edward, Earl of Clarendon, (dated July, 1UC8.) Oxford, 1761, vol. i. p. 16. of Butter. Parry, Black, Blackall, Eisner, Stoeller, Jahn, Desportes, Jurine, Brera, and Zechinelli. In the work of Zechinelli, in particular, a most ample collection of the recorded facts and opinions respecting this disease will be found ; although even his industry has failed to notice a consider- able number of important cases scattered through the medical literature of this and other countries. (Sulla Angina di Petto. Padova, 1813.) History of the Disease. — Angina pectoris is a disease of an intermitting character, in which the patient has intervals of comparative ease or of perfect health, between paroxysms of greater or less suffering. The paroxysm usually makes its first attack while the patient is taking exercise. Whilst walking or running, and more particularly if in the act of ascending an elevation at the same time, he is all at once seized with a most distress- ing sensation in the chest, usually in the region of the heart, or about the lower half of the ster- num and towards the left side. This sensation is variously described, as a pressure, or stricture, or weight; or as a positive pain of various character and degree, sometimes obtuse, sometimes acute,— tearing, burning, or lancinating. There seems always to be something peculiar in the pain, whatever be its degree, unlike the pains of other parts of the body, and as if it were combined with something of a mental quality. There is a feeling and a fear of impending death ; and the primary symptoms of corporeal disorder are speed- ily modified by the consequences of mental im- pressions conveyed through the nervous system.% The patient makes a sudden pause, eagerly catches hold of whatever is next him for support, perhaps raises the hand to some object above him to which he clings, or, it may be, imperceptibly sinks down on a chair or bank, as if unable to stand, yet afraid of the movements necessary to seat him. The face is pale, the expression of the countenance haggard, the whole body is covered with a cold sweat, and death appears to be impending no less to the inexperienced spectator than to the miser- able patient. Such, in fact, is sometimes the ter- mination of the paroxysm, but rarely, and scarcely ever in the early stage of the disease. After suffering in the way described for a longer or shorter period, varying in different cases from a few minutes to one hour or more, the patient revives, sometimes gradually, sometimes suddenly, and in many cases immediately resumes the feel- ing and the faculties of health. The pain is rarely confined to its primary and principal site in the cardiac region, but increases, in different instances, very variously both in direc- tion and extent. It shoots upwards or downwards, or to the right side, and almost always through the left side of the chest towards the shoulder and axilla, and very frequently into the left arm about the middle of the humerus, or as low as the elbow. Sometimes the pain in the last named places is extremely acute ; and, frequently, sensations of a similar kind, though less severe, are experienced all along the arm to the fingers, or in both arms, or along the throat and side of the face, and occa- sionally even in the lower extremities. Generally, U •' duidni ?" exclaims Seneca, reflecting on his own sufferings from this disease, " aliud enim quidquid est tegrotare est, hoc est animain agere." Epist liv ANGINA PECTORIS. 105 these pains in the limbs accompany or succeed that in the chest; sometimes they precede it. In most cases the respiration is unimpeded, although the patient seems at times as if he were unable or afraid to breathe. At other times, and perhaps more generally, deep inspirations are made, and are aided by raising the arms and shoulders, with the view of enlarging the chest as much as possi- ble. Sometimes the breath is retained for a con- siderable time. The pulse is found to vary considerably in different cases. Sometimes it is regular, some- times irregular; in one patient frequent, in another slow ; sometimes feeble, sometimes strong, and occasionally altogether suppressed; most com- monly, perhaps, it is regular, small, and weak. Eructations of flatus are almost always present, and when present generally afford relief. Fre- quently, indeed, in the less severe cases, the parox- ysms seem to give way immediately upon the supervention of the discharge; and the same result occasionally follows, but much less com- monly, a similar discharge downwards. In the commencement of angina, the attacks are, in gene- ral, comparatively mild ; and commonly increase progressively in severity as well as frequency, as the disorder is prolonged. In a certain proportion of cases, the symptoms are so mild as to give rise to doubts whether the affection is really angina ; the whole paroxysm often consisting of an instan- taneous pang in the situation of the heart, passing off nearly as soon as felt. In others, the pain is of longer duration, and is accompanied by more or fewer of the irradiations to remote parts which mark the severer paroxysms,— in particular, the pain of the left arm. In a third class of cases, the patient is suddenly invaded by an indistinct, very distressing, but not very painful oppression in the region of the heart. He is agitated and alarmed ; his sensations are distressing, his apprehensions are more so. He feels as if the heart were vio- lently compressed ; or as if it were distended and about to burst, or as if its movements were sud- denly arrested. This last sensation is the most common. In every variety of paroxysm, whether slight or severe, palpitation of the heart is not an unusual occurrence. Sometimes it precedes, some- times accompanies, sometimes follows the painful sensation ; but in many of the severest and best marked cases it is entirely wanting. Angina occurs in both sexes, and at all ages above that of mere childhood ; but it is much more common at particular periods of life ; and the severer cases, at least, are met with much more frequently in the male sex. Of eighty-eight cases related by different authors, and to which we have referred with a view to this particular ques- tion of sex, only eight occurred in females, being exactly one-eleventh of the whole; and of the total number of patients, twelve only were under fifty years of age. Were we, then, to be guided solely by the published cases, we should say that the common opinion, which represents the disease as especially affecting the male sex and persons advanced in life, is most just. No doubt it is so; but still it is necessary to make some allowance for circumstances connected with these recorded cases, before they can be received as srrounds for fixing the statistics of the disease, taken without Vol. I—14 reference to its degree of severity. The truth seems to be, that of the more severe cases, particu- larly such as depend on organic disease of the heart and large vessels, the great majority occur in the male sex ; while of milder cases, a very con- siderable proportion, perhaps an equal proportion, are met with in females, and at an earlier period of life. This, at least, is the result of our own experience ; and the same opinion is entertained by writers of great authority.* The same conclu- sions as to the greater frequency of mild cases in the female sex, and at an earlier age, are supported by certain other results of the published histories of angina. Thus, while only one-eighth of the males recovered, no less than one-half of the females did so, viz., four out of eight; and of these four, only one was above fifty years of age. But it is to be further recollected that the greater mildness and curability of the disease in women will partly account for the very small proportion of this sex among the published cases. The very severe cases naturally attract more attention, more particularly if, as often happens, they have been terminated by a sudden death, and followed by a dissection ; and these are the cases that are usu- ally recorded and published ; while others of pre- cisely the same nature, but differing in degree, are too often overlooked or even forgotten. From these considerations, therefore, and from our own observations, corroborated by those of Jahn, Ho- sack, Laennec, &c, we are disposed to believe, that while among the severe examples of the dis- ease, the proportion of males to females may be even greater than is commonly believed ; among the milder cases, theie may be found as many women as men. There is no situation in life peculiarly exempt from this disease ; but it attacks some classes of persons much more than others. Like many other diseases, angina is the attendant rather of ease and luxury than of temperance and labour ; on which account, although occurring among the poor, it is more frequently met with among the rich, or in persons of easy circumstances. This fact alone shows that its attacks are much more influenced by adventitious circumstances than by natural temperament. The same remark applies to the reported prevalence of the disease in particular seasons, and in what has been termed particular medical constitutions. (Laennec, De PAuscult. Med.) It must, however, be admitted that the greater number of cases depend on causes of too fixed and too formidable a quality to be modified by circumstances of this kind. Although by no means of rare occurrence, an- gina cannot be said to be a common disease, more particularly in its strongly marked form. In the numerous instances of organic disease of the heart constantly met with in practice, symptoms which may be termed irregular angina, namely, more or less of pain or uneasiness in the region of the heart, suddenly coming on during exercise, and obliging the patient to stand still for a short time, are complained of, in almost every case, in a greater or less degree ; but the severe affection described by Dr. Heberden and his followers, and of which an outline has been given in the beginning of this * Jahn. TJeber die Syncope Anginosa Parry. Hide. land's N. Journ. Ic06. 106 ANGINA PECTORIS. article, is certainly not of frequent occurrence. It is proper to observe, however, that the great im- provements which have taken place of late years in pathology, by enabling practitioners to connect symptoms with their organic causes more accu- rately, have necessarily diverted the attention from the artificial combinations of the old nosology ; and as the knowledge of cardiac affections has, moreover, been particularly increased by the dis- covery of a very superior instrument of diagnosis, it is probable that many cases which the older authors would have referred to angina, have of late years been looked upon and recorded simply as diseases of the heart. If only the well-marked cases are taken, it will be found that the whole number recorded in the works of our English writers since the time of Heberden, as well as in those of the best authorities in France, Italy and Germany, does not much exceed one hundred. If we were to form our opinion solely from the results of the published cases of angina, we should say that it was one of the most dangerous and fatal of diseases. For instance, in a list of sixty- four cases now before us, of which the result is recorded, no less than forty-nine proved fatal, almost all suddenly ; while of the remaining fif- teen the greater proportion are recorded as relieved only. But we are by no means disposed to receive such results as coming at all near the truth, as regards the disease generally. Most of the cases in the above list were examples of organic disease of the heart or large vessels ; and if we were to limit our views to this class of cases, the propor- tion of deaths above stated is probably less than the truth. But we shall find that a very large class of cases, legitimately ranged under the head of angina, have no necessary dependence on struc- tural lesion of the heart ; and of these the general result will be found very different from that re- corded above. It is from having overlooked this last class of cases, that most of the earlier writers on angina considered it as almost inevitably fatal; and it is, perhaps, from giving too exclusive an attention to the milder forms of the affection, that some other authors have taken a view of it per- haps as much too favourable as the others did the reverse. Of the latter class of writers, Laennec, Hosack, and Butter are the principal. Laennec considered the disease as extremely common in its milder forms, and did not regard it, in general, as a severe disease. (Loc. Cit.) Dr. Hosack believes the severity of the affection to have been much exaggerated, and looks upon it as very much under the influence of medical treatment.* Dr. Butter, who considered angina to be a species of irregular gout, says that he must " impute the chief, if not the sole, difficulty of curing the disease to the want of conformity of the patient himself with regard to diet."-j- The following synoptical view of some of the statistical details relating to angina will be found convenient for reference, and is, therefore, sub- joined, although in some respects a repetition of what has gone before. A. Results relative to the sex of the patients. Total number of cases examined,....................88 Of these were, men......................80 B. Results relative to tkt age of the patient*. Total number whose ages are recorded,......• :- • • •« Of these were, above fifty. under fifty- 64 C. Results relative to the event of the cases generally Total number of patients, the event of whose cases is recorded,........................'.'" i'."'•' i' Mn Of these there died (almost all suddenly). .49 Were relieved or recovered..............15 D. Resvlts relative to the event of the cases as regards sex. I. Total number of fatal cases.......................49 Of these were, men............... ..........47 women..................2 2. Total number of cases cured or relieved............15 Of these were, men.....................11 women.................. 4 * Essays on various Subjects of Med. Sci., vol.ii. 268. f Treatise on Angina Pectoris, 2d edition p. 24. Causes.__Under this head, we shall at present notice only the exciting causes of the paroxysms. The remote and predisposing causes will be con- sidered with more practical advantage, athough with less logical catenation, when we come to treat of the different varieties of the disease, and the means of preventing and curing it. The exciting causes of the paroxysms of angi- na, or the circumstances under which they occur, are, in general, so well marked, and so constant and uniform, that they might almost have been included in the description of the disease. They may be stated in general terms, to be all such as accelerate the flow of blood, or suddenly increase the action of the heart. The principal of these circumstances are all kinds of bodily exercise, as in walking, running, straining, &c, and the more powerful emotions of the mind. Of all the move- ments of progression, that of going up stairs or up hill is by far the most effective in inducing a paroxysm ; and it has been frequently remarked that, ceteribus paribus, walking against the wind is considerably more injurious than walking in a contrary direction. Sometimes even walking in the open air in perfectly calm weather has induced a fit, when the same degree of exercise within doors has had no such effect. (Medical and Phy- sical Journal, vi., p. 320.) In some rare instances, the first paroxysm has been induced suddenly during powerful bodily exertion, as in leaping, raising a weight, &c.; J and in such cases, it has been found that a slight rupture has taken place in the valves of the heart or their appendages. In the earlier shiges of a severe disease, and through the whole course of mild cases, the attacks are commonly induced by the more powerful of the causes mentioned, or by others of an analogous kind ; but as the disease increases in severity, the slighter causes of the same kind suffice to excite a paroxysm. Thus, in some unhappy individuals, almost any .general bodily movement, such as the act of turning in bed, or walking across the room, or coughing, sneezing, or relieving the bowels, or even thinking intensely, will occasion a seizure In subjects of such extreme susceptibility, paros- ysms will, of course, frequently occur without any very obvious cause. Any of the causes being applied immediately after a meal, acts with much greater certainty and force ; and sometimes the mere presence of a full meal in the stomach seems sufficient to excite a paroxysm. In certain cases, the attacks occur most frequently at night, on the patient awaking from sleep, as is so frequently the 1 Blark in Mem. of Med. Society of London iv p. 61. Blackall oil Dropsy, 3d edition, p. 381. ANGINA PECTORIS. 107 case with paroxysms of asthma ; and this circum- stance is one of several which have led some writers to consider angina as allied to that disease. Pathology of Angina.—In a perfect system of philosophical medicine, founded on the basis of the pathological condition of the organs primarily affected, angina, such as we have described it in the preceding pages, would be banished from the list of individual diseases ; since it cannot be denied that the various phenomena which consti- tute the paroxysm may be present in different states of the system, or may even originate, as far as we know, in different states of the very organ in which we believe them to have their site. In such a system, it could only be regarded as a group of symptoms — frequently found co-exist- ing, it might be — but still merely the incidental attendants of different diseases. But as it is im- possible, in the imperfect state of our actual know- ledge, to say, in the case of angina, as in that of so many other diseases, what morbid phenomena are essential, and what merely contingent, we shall attempt no such refinement on the present occasion, but following the steps of our numerous predecessors, shall treat of angina as a distinct disease. In common language, the term angina pectoris is frequently restricted to the more prominent phenomena of the paroxysm, as above described; and there can he no harm in so applying it, pro- vided its restricted meaning is not misunderstood. But when the disease angina is reearded in the comprehensive point of view which can alone lead to important practical results, it is very far from being confined to the limits of the paroxysm. On the contrary, it must be considered as compre- hending all the derangements of the system, gen- eral and local, which precede, accompany, or fol- low the paroxysm, or which can in any way be regarded as influencing it. This is the notion of the disease which exists in the mind of every ex- perienced practitioner; and this is the sense in which the word angina is generally to be under- stood in the present article, although it will be observed that we have already been using it in its more restricted meaning. Seat and nature of the disease. — Numer- ous considerations prove that the pain in the paroxysm of angina has its primary and principal seat in the heart or annexed great vessels. 1. The patients almost always refer their agony to the region of the heart; the more distant pains of the ■houlder, arm, &c, appearing to spring from this primary source, and being, in almost every case, subsequent to the invasion of the paroxysm.* 2. The peculiar character of the patient's suffer- ings, partly physical, partly mental, the anxiety, dread, &c, are such as could only be produced by the affection of an organ like the heart, on whose action life so immediately depends, and whose disturbance is so instantly perceived by the sen- 6orium. 3. The exciting causes of the paroxysm are always such as are especially calculated to dis- * In a few cases the pain has been found to commence in the arm, and dart from this to the breast. But we believe this has alw ays been in cases of lone standing:. We are aware of no case of recent origin in which such an occurrence lias been observed, And this distinction is important. turb the natural action of the heart; namely, bodily exertion, emotion of mind, compression of the heart by the encroachment of other organs, &c. 4. The frequently fatal termination of this disease, and the suddenness of the death, are only to be explained by disorder of the heart or great vessels, as the affection of no other organ in the chest or abdomen could produce such a result. 5. But all these presumptive proofs, if we may so term them, are corroborated, and, indeed, confirm- ed, by the physical condition of the heart itself, ascertained by dissection in fatal cases, and by the stethoscope during the life of the patients. In a vast majority of the fatal cases of angina of which dissections are recorded, there has been found great structural disease in the heart, or aorta, or both. In these cases, there can scarcely be a doubt entertained that the pain was seated in the heart or great vessels ; and as the character of the pain and other symptoms in cases in which no organic lesion is recorded, have been observed to be precisely similar to those occurring in the former, it would seem unjustifiable scepticism to disbelieve that both had the same site. There seems nothing improbable, much less impossible, in a heart altogether of healthy structure becom- ing the site of such a pain ; but there is reason to believe that, in the few cases of fatal angina in which no organic lesion was found on dissec- tion, the heart was not exactly of just proportions or of perfectly sound structure. We found this opinion partly upon the published accounts of those dissections, and partly on our own observa- tions both on the dead and living subject. It is easy to overlook slight misproportions in the dif- ferent cavities, and also various morbid conditions of the muscular fibre of the heart, which may have sufficed, nevertheless, to occasion the great- est distress or disorder in the action of the organ. And in many cases of the milder forms of angina, we have been enabled to ascertain during life, by means of auscultation, that the heart was not ex- actly of healthy proportions, either in relation to its own parts individually, or to the system gen- erally. With the view of more fully corroborating the accuracy of these statements and opinions respect- ing the seat of pain in the paroxysm, we subjoin a brief outline of the results obtained on dissec- tion, in some of the principal cases recorded by authors since the time of Dr. Heberden. A. Results relative to the existence of organic disease in general. Total number of cases of which dissections are given..............................................45 Of this number there was no organic disease (ex- cept obesity) in.................................... 4 ------Organic disease of the liver only, in..... it —---Organic disease of the heart or great ves- sels, in............................................39 B. Results relative to the nature of the organic affections of the heart and great vessels. Total number of cases in which there was organic disease in the heart or vessels.......................39 Of this number there was organic disease of the heart alone, in...............................•.....10 -------Organic disease of the aorta alone, in.... 3 ----—Organic disease of the coronary arteries alone, in........................................... 1 ------Ossification or cartilaginous degeneration of the coronary arteries, in.........................16 ------Ossification or other disease of the valves, in.................................................16 PECTORIS. 108 ANGINA I -------Dispose of the aorta (ossification, or dila- tation, or both), in.................................24 -------Preternatural softness of the heart,* in.................................................12 If we consider it as proved, by the foregoing statements, that the heart and its great vessels constitute the seat of the pain and all the prin- cipal phenomena of the paroxysm of angina, it still remains to be inquired what is the nature of this pain, and what are its immediate causes, or the circumstances on which it immediately de- pends. And there seems no great difficulty in coming to a satisfactory conclusion in this matter, if we keep in view; 1. the facts recorded relative to the frequency of structural disease in the heart and aorta in angina; 2. the characters of the pain itself, its instantaneous invasion and cessation, its violence, its short duration, and its complete dis- appearance for long periods of time ; 3. the nature of the actions of the heart and great vessels in health ; and, lastly, the nature and causes of pain- ful affections in other parts of the body. We have no doubt that the pain, and other principal phenomena characterising the paroxysm of angina, may acknowledge different causes and depend on different conditions of the affected parts, in different individuals, and in the same individual at different times ; just as we find in other parts of the body, more particularly in parts possessing a structure and functions somewhat analogous to those of the heart; namely, the hollow viscera possessing muscular tunics, and destined to con- vey fluids. The stomach, the intestines, the blad- der, the gall-ducts, ureters, &c, are all subject to sudden paroxysms of severe pain, frequently originating in very different causes, yet very simi- lar in their external character. In the stomach or bowels, for example, we may have gastralgia or enteralgia, of the same general appearance, from pure muscular spasm ; from matter irritating the internal membrane ; from simple neuralgia, the source of irritation being at the origin of the nerves; from over-distension, &c. &c. ; and each of these may exist with various organic diseases of the part, or without any organic disease ; and two or more of them may co-exist. It is reason- able to suppose that painful affections of this kind will much more easily be produced in a diseased organ than in a sound one ; and, indeed, experi- ence proves, that although almost all organs are liable to severe pains, from some unknown tem- porary condition of the nerves themselves, usually termed neuralgia ; yet that they are much more liable to such painful affections when diseased in their structure, and consequently disordered in their action or enfeebled in their powers. From what has been already stated of the frequency of structural disease of the heart and aorta neces- sarily disordering their action, it will readily be understood how easily pain may be induced in these parts under various circumstances, and from many different causes ; and it seems equally in- telligible how similar pains may originate in the same parts, under particular circumstances, even when no structural lesion exists in them. In this, as in so many other cases, authors have fre- quently failed in accounting for the phenomena, because they took too confined a view of the sub- * In a great many cases the consistence of the heart is not noticed. ject, and were anxious to establish a greater sim- plicity in the production of the symptoms than nature acknowledges. Of the intimate nature of the pain in the pa- roxysm of angina we know nothing ; but we know no more of the nature of any pain. AH that we can propound concerning it is a relation of the events which seem to lead to it, and the condition of the parts in which it occurs, at the time of its occurrence. We know that the pain is not of that kind which arises from inflammation, or ulce- ration, or any other fixed physical alteration of a part. All the circumstances attending it prove it to be of that kind which occurs in cramp or spasm, or from pressure, or in the class of cases termed neuralgic, in which the painful sensation is the result of some unknown temporary condition of the nerves of the part, not manifested by any physical alteration of them discoverable by our senses. We have sufficient evidence that such a morbid condition of the nerves may be produced in a heart in all other respects sound ; and when it takes place in a heart manifestly diseased in its structure, we must consider the structural lesions merely as predisposing and exciting causes of the pain. That the structural lesions are not the im- mediate and necessary source of the pain is suf- ficiently proved by its intermitting character, and the perfect ease in the intervals, when the struc- tural lesion is precisely the same as during the paroxysm. The anatomical structure, the pecu- liar action and functions of the heart and annex- ed great vessels, will sufficiently explain all the modifications of the pain and other phenomena observed in the anginous paroxysm. The radia- tion of the pain to a distance from the primary and principal site of it is only in conformity with what is observed in all other painful affections. Stone in the bladder produces pain in the glans penis ; calculus in the ureter, pain in the ab- dominal walls ; inflammation of the cartilages of the hip-joint, pain in the knee ; and what is per- haps a still more appropriate illustration, irritation at the origin of nerves in general frequently mani- fests itself only by pain at their extremities. In a word, the pain, in the paroxysm of angina, may arise from neuralgia, from spasm, from over-dis- tension ; and the other principal phenomena, may all, we think, be explained by the derangements of the functions of the heart, considered as a muscular organ charged with the office of circu- lating the mass of blood. Varieties of Angina*—Under this head we do not mean to notice the different forms of the paroxysm as witnessed in different cases. Such distinctions are of little practical value. We wish here to advert to the different circumstances, whe- ther of a local or general kind, under which the paroxysms take place, and which may materially influence both the prognosis and the treatment. Some of the most remarkable of these differences have reference to the physical condition of the parts immediately affected in the paroxysm ; others to the state of the general system with which the local affection is connected. We shall briefly notice the chief of these varieties in the order now stated. In one class of cases there exists great structu- ral disease of the heart and aorta; in another ANGINA PECTORIS. 109 class there exists either no structural disease, or none that can be detected. The former class of cases may therefore be termed organic angina ; the latter, functional angina. Each of these classes may be subdivided according as the affection of the heart and aorta exists uncomplicated with other diseases of a general or local kind, or co- exists with some such disease or diseases on which it is more or less dependent. This classification would give the following arrangement:— I. Organic angina. 1. Pure, or idiopathic. 2. Complex, or sympathetic. II. Functional angina. 1. Pure, or idiopathic. 2. Complex, or sympathetic. 1. The cases that come under the first subdivi- sion of organic angina are few in number. They are those in which the anginous paroxysms seem to be the direct consequence of organic disease of the heart occurring in persons otherwise healthy. Cases of this kind are seldom very well marked, the anginous symptoms being either feebly mani- fested, or overpowered by the greater intensity of the more ordinary symptoms of heart disease. These may be considered, in one respect, as the worst cases of angina, inasmuch as they hold out little prospect of cure or even of alleviation. Our influence over diseases of the heart is very slight, except they are partly the effect of some other disorder of a more curable kind. 2. Under the next subdivision of organic angi- na, we would include the greater number of the best marked and more severe cases of this disease. In these, along with the organic affection of the heart or vessels, or both, (probably not very great, or, at least, marked rather by the paroxysm of an- gina than by the general symptoms of diseased heart,) we have some obvious general disorder of the system. In cases of this kind, the organic disease of the heart and aorta seems often to be a consequence of the co-existing disorder; if not a consequence, it is always greatly aggravated by its presence ; and hence the most successful medi- cal treatment of the angina is that which has direct reference to the concomitant disorder. Among the various structural affections former- ly detailed as constituting the essential or organic character of these two classes of cases, different authors, at different times, have been anxious to select some one lesion as the exclusive cause of the disease. The principal of these have been,— ossification of the coronary arteries, ossification and dilatation of the aorta, accumulation of fat in or around the heart, &c. To these may be add- ed, with equal propriety, several other morbid states of the heart, particularly—softening of the muscular substance of the heart, dilatation of one or more of the cavities, &c. It will be at once admitted as a necessary consequence of the result of the dissections given above, that no one of these lesions is entitled to be considered as exclu- sively the cause of the paroxysm of angina ; and that some of those which have been most gener- ally believed to be such, are equalled or exceeded in point of frequency by others. Thus we see that the ossification of the coronary arteries, for- merly considered by so many as the chief or sole cause of the paroxysm, is only of the same fre- K quency of occurrence as disease of the valves, while disease of the aorta is much more frequent than either. But we think it probable that much slighter deviations from the normal condition of the organs of circulation than any above noticed constitute quite as frequent causes of this disease ; more particularly of the milder cases. In a cer- tain proportion of this class of cases it is not always possible to detect, during life, the exist- ence of any organic lesion, much less the precise lesion ; and from the same cause, (its slightness,) it is frequently overlooked in the examination after death. In a considerable number of such cases, however, the nature of the morbid deviation is discoverable both during life and after death. The most common of these slighter deviations from healthy structure are, a thin and slightly dilated state of the ventricles, and a want of tone in the muscular fibre. 3. We consider cases of the kind just mention- ed, In which the organic deviation is so slight as to be hardly discoverable, as constituting the great- er number of those usually viewed by practitioners as examples of pure functional or nervous angina. It is obvious that in extreme strictness of lan- guage they are not entitled to this name ; yet if the deviation is only so slight as to constitute mere feebleness, (and it is often nothing more,) they are probably as well entitled to the name as most other diseases commonly denominated nervous. But it must be admitted that in persons possessing the best- proportioned hearts, and in which no de- viation whatever from the normal structure can be detected either during life or after death, there may and do occur paroxysms of angina. The proportion of such cases is however very small under any circumstances in a state of uncompli- cation with other diseases; and we look upon them rather as of possible occurrence than as hav- ing certainly met with them in practice. Con- joined, however, with some other disorder, as in the next class of cases, we conceive they are by no means rare. 4. Under the head of complex or sympathetic functional angina, we must comprehend a large class of cases ; and, for the reasons stated in the last paragraph, although not strictly philosophical, we would, for practical purposes, include under the present division all the cases of nervous angi- na complicated with other diseases, whether the organs of the circulation are perfectly sound and well proportioned, or only deviating in a very slight degree from this state of integrity. Under this head are comprehended a very considerable proportion of the cases met with in practice, and not a few of those which present symptoms of the greatest severity in the paroxysm. The limits of this article prevent us from enter- ing into any lengthened details respecting the morbid states, general or local, which complicate angina, whether as simple coincidents or as predis- posing causes. It is highly necessary, however, that the attention of the practitioner should be particularly called to them, since, as has been al- ready observed, almost all our remedial measures must be directed rather against these complications than against the local affection which gives the disease its name and character. Of these complications, there is none more no ANGINA PECTORIS. deserving of notice than that multiform affection which is most commonly known by the name of dyspepsia. In its earliest and simplest stage, when consisting chiefly of mere functional disor- der of the stomach, this affection is a frequent concomitant of angina, and sometimes is the ex- citing cause of the paroxysms. In nervous habits it gives rise to much general disturbance, and ag- gravates local diseases, both by inducing general debility and exciting particular sympathies. It is, however, in its latter and more complex stages, that dyspepsia displays its principal power in modifying the condition of the system ; and it is in these that its connexion with angina is most conspicuous. In place of mere functional disor- der of one organ, there are now fixed structural changes in many ; while numerous new functional disturbances are added to the primary one, and all are become fixed by long habit. The mass of blood itself, and most of the secretions and excre- tions have likewise become changed both in quan- tity and quality. This general disorder of the system, which may be termed secondary dyspepsia, sometimes gives rise to symptoms of angina, without any previous organic affection of the heart or aorta. It fre- quently also produces organic affections in these parts; and if these already exist, it is one of the most common and most powerful exciting causes of the anginous attacks. When, co-existing with angina, this general disorder, in its progress, gives occasion to other local diseases of a fixed charac- ter, the consequence is sometimes an alleviation of the anginous symptoms, sometims an aggrava- tion of them. The organs which principally suf- fer in this way are the brain, the liver, the uterus, and the skin. When the irritation has fixed itself in the brain, the case becomes more distressing and unmanageable ; as then, in addition to the various bodily disorders, we have to combat the fretfulncss and fickleness of a depraved temper, and all the mental miseries of hypochondriasis. There is no mistake more prevalent in this country, or more practically injurious, than that inflammation or other organic lesions of the liver are of frequent occurrence as primary diseases; much more, that they are among the causes which exert the most powerful influence in modifying conditions of the whole system, and in exciting, by their sympathetic relations, numerous other maladies. Functional disorder of the liver is, no doubt, a very common effect of secondary dyspep- sia ; and when this has subsisted a long time, structural lesion, under the form of chronic inflam- mation, or induration, or hypertrophy of the gland, may be the consequence. But we are well assured that disease of the liver is rare in this country as a primary affection ; and we believe that when it exists, it exerts less influence over the rest of the economy than is commonly believed. When, from any cause, hypertrophy of the liver has arisrn, the viscus may encroach, more or less, upon the natural boundaries of the chest, and impede or derange the healthy movements of its contents. And it is from having seen some cases of this kind, and from having overlooked the more powerful agency of the accompanying disorders, that Brera, Portal, Latham, and others, have considered angina as a mere sympathetic affection of the heart produced by the encroach- ments of the liver, or other abdominal viscera, on the boundaries of the chest. Nothing can be more incorrect than this view of the case, as ap- plied to angina generally. It is open to the charge of overlooking numerous and obvious causes of a much more influential kind, and selecting one that is at once insignificant and of rare occurrence. The affections of the uterus seldom extend be- yond the mucous membrane ; but as irritations of this organ are important, both as creating local drains, and as producing, by extensive sympathy, irritation and disorder in the nervous system ; and as they, moreover, very generally induce some de- rangement of the important function of menstru- ation ; they deserve great attention from the prac- titioner when they complicate angina. One of the most constant and important com- plications of angina is that state to which we com- monly give the name of plethora, and which is supposed to consist essentially in an overloaded condition of the vascular system, in other words, a superabundance of blood. It is probable, how- ever, that in the great majority of cases, the blood is altered in its quality no less than in its quan- tity, the most common alteration being an increase of its nutritive properties. This, at least, is the most usual condition of it observed in angina. Independently of actual proofs of the existence of such a state furnished by the symptoms, almost everything in the history of angina countenances such an opinion. 1. The subjects of angina are mostly of the male sex, above fifty years of age, and a great majority of them belong to that class of persons who are enabled to indulge in full liv- ing, without the necessity of undergoing severe bodily labour, or even of using active exertion. 2. Gout is a very frequent disease in persons sub- ject to angina; and gout scarcely ever occurs (except in extreme cases of hereditary predisposi- tion) in persons that are not of a plethoric habit. 3. Obesity is extremely common in angina. The deposition of fat in the internal parts is, indeed, so common, that many writers are disposed to consider the fatty accumulation as the cause of the paroxysms. 4. The very existence of angina, from whatever cause arising, tends to produce ple- thora if it did not previously exist, or to increase it if already present. A sedentary life, and the abandonment of all active bodily exertions, are almost inevitable consequences of this disease; and if the appetite continues good, as it often docs, and if no dietetic regimen, having reference to the diminished wants of the system, is enforced, the occurrence of plethora can hardly be avoided. 5. We consider the formation of osseous deposits in the aorta, coronary arteries, &c, so prevalent in angina, as an indication at once of plethora and of that concomitant depravation of the blood which we know generally to precede the deposi- tion of analogous morbid substances in gout, cal- culus, &c. 6. The beneficial effect of various kinds of medical depletion and low living, and the ill effects of opposite practices, strongly corrobo- rate the same view of the case. The connexion of angina with the gouty habit deserves some further notice, as being a matter of great importance in respect both of the pathology and treatment This conuexion was early ob- ANGINA PECTORIS. Ill served, and has had considerable influence in modifying the opinions and practice of many writers on the subject of the present article. But- ter seems to have been the first who particularly noticed it. He, indeed, considered angina as no- thing more than a form of gout. Similar opinions are entertained by many subsequent writers, as by Macqueen, Eisner, Stoeller, &c. ; and when stated with due regard to philosophical accuracy of lan- guage, there can be little doubt that this opinion is correct in a very considerable number of the cases of angina. The fact is, that in such cases there exists the same general disorder of the sys- tem as in gout, of which one of the most obvious features is the state of plethora above mentioned. In a certain proportion of these cases we have all the local characteristic phenomena of gout, either co-existing or alternating with angina ; in others we have the same constitutional symptoms, but the local disorder of the heart and great vessels in place of that of the joints. No doubt, there exists some real difference between the two classes of cases, which gives to one the characteristic form of angina, and to the other that of gouty inflam- mation of the extremities ; but the nature of this difference altogether eludes our observation in most instances. It is sufficient for our present purpose to be aware of the fact that, in a certain proportion of the cases of angina, the same appa- rent constitutional disorder exists as in gout. This fact is abundantly proved by the evidence afforded by the published cases of angina, and is corrobo- rated by all that we have ourselves observed of this disease. Treatment of Angina.—Like that of all dis- eases of an intermitting or paroxysmal character, the treatment of angina requires to be considered in two very distinct points of view,—in the pa- roxysm, and in the interval. We shall therefore notice these separately. I. Treatment in the paroxysm.—As there can be no doubt that the paroxysms of angina arise under very different conditions of the system, and as they differ very materially in their immediate rauses, or in the condition of the organs immedi- ately affected, all rational treatment must have re- gard to these circumstances in individual cases, as far as they are known or can be ascertained. Painful muscular spasm, or simple neuralgia of the heart and aorta, whether ultimately depend- ing on organic disease of the parts or not, may recognise very opposite exciting causes, and may, therefore, lie best relieved by different means. In one case, for instance, the patient may be strong and robust, and his whole vascular system overloaded ; in another, he may be the victim of long previous disease, with a deficiency both of blood and constitutional power ; while, in a third, the system may be comparatively healthy, with or without local disease of the organs of circulation, and with or without great nervousness of tempe- rament. In all these varieties, the treatment will require modification to suit it to the individual case. When previously known, such circum- stances must, therefore, be kept in mind by the practitioner; when not known, an attempt must be made to ascertain them before he prescribes for the patient. Inattention to circumstances of this kind has often rendered the treatment much less effective than it might have been, or has rendered it decidedly injurious. It must be confessed, how- ever, that in many cases it is extremely difficult, if not impossible, to come to any certain judgment as to the actual pathological condition of the affected parts, or even of the system generally, during the paroxysm. A previous knowledge of the patient, and, yet more, the having had oppor- tunities of studying the case in former attacks, will here be of the greatest importance. The violence of the patient's sufferings, and the belief in the nervous or spasmodic nature of the pain, suggested by its sudden invasion, would na- turally lead the medical attendant, in the first place, to attempt to afford relief by anodynes. And such, we find, has been the common prac- tice of physicians when first called to a patient in a paroxysm, or when requested to prescribe means with the view of checking or mitigating its vio- lence in case of recurrence. Such attempts, how- ever, have generally been attended with less suc- cess than might have been expected. Rarely, in- deed, if ever, has a paroxysm been speedily and completely removed, by such means; and only in a very small proportion of cases has its violence been mitigated. In angina, as in tooth-ach or tic douloureux, gastralgia, colic, or other violent pains, nature seems as if she scorned to be con- trolled by art, although so much under the influ- ence of similar applications when less needed, as in the case of milder pains. And, no doubt, in the disease now under consideration, the state of mental distress and fear with which the bodily suf- ferings are complicated, has a powerful influence in counteracting the ordinary effect of anodyne remedies. Our own experience would lead us to recommend the use of anodynes in the milder cases only ; and more particularly in those in which there existed a feeble and exhausted sys- tem, or great constitutional nervousness without plethora. Antispasmodics, cordials, carminatives, &c, have been also much recommended and employed; and, upon the whole, with better success than anodynes. They have appeared, in different cases, to afford relief by imparting a temporary vigour to the nervous system generally, overpow- ered as it seemed by the bodily and mental suf- ferings ; or by stimulating the heart to increased action, and thereby enabling it to propel the load with which it was oppressed ; or, simply, by in- vigorating the stomach, and enabling it to expel the flatus accumulated in it And it seems pro- bable that such means may operate in all these ways, and, perhaps, conjointly in the same case. In cases in which there exists sufficient evidence of a plethoric state of the vascular system, some attempt must be made to remove this before means of the kind now under consideration can be ap- plied with any prospect of benefit, or even safety. In most cases where venesection has been em ployed, and particularly if it has been carried to a considerable extent, slight doses of laudanum, combined with brandy or other stimulants, may be used, always with safety, and often with be- nefit ; and the probability of benefit will be greater, in proportion to the degree of exhaustion and nervousness present. The aromatic and stimulant medicines, usually termed carminatives, are more 112 ANGINA PECTORIS. particularly indicated in dyspeptic complications, and where there exist signs of distension of the stomach by flatus. This circumstance of the stomach being so ge- nerally oppressed with flatus during paroxysms of angina, and of the expulsion of this being al- most always the harbinger of relief, if not its cause, is a remarkable feature in the history of the disease. In reading the numerous cases re- corded, one is struck with the frequent mention of this circumstance; and our own experience entirely corroborates the observations made by- others, that it is by no means rare in subjects who are altogether free from any signs of indi- gestion in the intervals of the paroxysms. From this and other considerations, there seems little reason to doubt that the gas is formed in the in- testinal canal during, or immediately before, the paroxysms. Be this as it may, there can be no doubt that its expulsion during these, forms, in most cases at least, a rational indication of treat- ment ; since, whether a cause or consequence of the paroxysm, its expulsion almost invariably gives relief:* and it is sometimes found that the simple aromatic waters are more effectual in pro- ducing this result, than medicines usually consi- dered of greater power.-|- A very different mode of relief, already noticed, namely, venesection, has been occasionally em- ployed with much advantage ; and there is great reason for believing, that, if more judiciously ap- plied, it would have been still more beneficial. Several different circumstances met with in pa- roxysms of angina, sometimes separately, some- times conjointly, seem fully to justify the trial of this remedy, even if its use had not been vindi- cated by experience. These are, the state of ge- neral plethora, so frequently found in such pa- tients ; the state of actual local plethora or morbid accumulation of blood in the heart and large ves- sels ; the state of relative local plethora of the same parts from feebleness of the organ in pro- pelling its contents. In all these cases the dimi- nution of the mass of blood, if it can be effected without immediate risk of life, would unquestion- ably be beneficial; and the practice of several eminent men has proved it to be often safe. Dr. Percival, Dr. Parry, Dr. Hosack, Mr. Allan Burns, and several others, are of this number. We have ourselves employed it with benefit in some strongly marked cases of angina; and the instantaneous and signal relief which every physician must have often observed from venesection in organic dis- eases of the heart, leaves no doubt of its useful- ness in this disease, when employed with discri- mination, and with the necessary precautions. These precautions are well stated by Dr. Parry in his Inquiry, in the following terms : " The patient should be placed in the horizontal posture, and * The apparent influence of gas in the stomach over the motions of the heart is very remarkable. In certain nervous diseases, we have seen intermissions of the heart's action carried to such an extent that the patient's life was considered in imminent danger; and yet have known the whole symptoms instantly removed by the sudden expulsion from the stomach of a quantity of flatus! t In a case related by Dr. Fothergill, simple pepper- mint water is said to have given great relief in this way : " It was always by him in the night, and gave him ease when a reasonable dnsp of paregoric had been given without benefit." Fothergiu's Works, ii. 253. blood should be taken away from a very small orifice, while, at the same time, the finger of the physician is applied to the pulse, in order to de- cide on the propriety of continuing or discon- tinuing the flow of blood. If no person of ade- quate judgment is at hand, it may be right to re- strict the quantity of blood taken away to about three ounces at any one operation." (On Syn- cope Anginosa, p. 164.) We have already stated, that where this measure is deemed ad- visable, it ought to take precedence of the ad- ministration of cordials, which are much more likely to act beneficially after the heart has been partially freed from the load which was oppress- ing it: and such remedies will, in most cases, be very properly administered after detraction of blood.* As the affusion of cold water in the paroxysm of angina has been mentioned as a remedy by some authors, we notice it here chiefly with the view of entering a caution against its employment. It can rarely be employed with benefit or even safety. The partial application of cold water, however, may be sometimes admissible as a stimu- lant of the nervous system, just as we apply it in hysteria. A curious case of severe angina is re- lated by Joseph Frank, in which the patient a medical man, found singular relief from the appli- cation of cold water to the head ; and the relief was more speedy, if, during the application of the water, the left hand was placed, in a particular manner, on the head. The same author relates a case in which the impending paroxysms seem to have been averted by the cold affusion ; but, as already stated, we cannot consider such a practice as generally safe.§ [Laennec affirmed, that the remedy which most frequently succeeded with him in procuring alle- viation, in cases of angina pectoris, and of neuralgia of the heart of a slighter kind, and without radiating pain, was the magnet; which he employed in the following manner : two steel plates, strongly mag- netized, of an oval form, and slightly arched, so as to admit of close application to the parietes of the thorax, were placed,— the one on the left pericar- dial region,—the other on the opposite part of the back, in such a manner that the poles may be exactly opposite, and the magnetic cui-rent may traverse the part affected. When it procured but little relief, a small blister was applied under the anterior plate with advantage. Dr. Hope (Trea- tise on Diseases of the Heart, Amer. edit, by Dr. Pennock, p. 466 : Philad., 1842,) states, however, that they who witnessed the application of the magnet by Laennec, did not, in general, form so favourable an opinion of its utility as he did. It appeared to be more successful when combined with acupuncture. Its effects are doubtless alto- gether revellent] But although these or other means may occa- sionally afford relief, or may even ward off death, it is evident that every kind of treatment confined to the paroxysm is of very slight importance, when X A strongly marked instance of the good effects of venesection in the paroxysm of angina is given bv Dr. Read,,., the Dublin Trans. Vol. i 105; and a good illus- ;»t ,"V°^ ■ , ll,JurTS *',ffe,'t* of Prematurely stimnlat- i™™^1" nart ?lready oppressed with its content*, is recorded in Parry's work, p. ]G3. § Prax. Med. Univ. Part ii., vol. sii. p. 273i 274i nota. ANGINA PECTORIS. 113 compared with that which is to be employed in the interval : the former can, at most, afford tem- porary relief; the latter may cure the disease. It is to this part of the treatment, therefore, that the care of the practitioner is to be chiefly directed ; and it is to this part of our subject that we would claim his especial attention. II. Treatment in the interval.—If it is of con- sequence for the practitioner to be acquainted with the precise nature of the case before him, to ena- ble him to prescribe successfully or even safely in the paroxysm of angina, it is much more impor- tant that he should have this knowledge to direct his treatment in the interval. In many cases, no doubt, it is quite impossible to ascertain the inti- mate character of the affection during the parox- ysm ; and in a certain proportion of these, the knowledge, if attainable, would be of liltle use. We should still be reduced to the necessity of ap- plying the same limited stock of means without any very inspiring confidence of a beneficial result. Circumstances, however, are very different in the interval. Here, an accurate acquaintance with the nature of the individual case is indispensably ne- cessary to enable us to institute treatment that holds out any prospect of success ; while a prac- tice adopted at hazard, or on merely empiricial principles, may not only be useless, but may lead to the most disastrous results. The first and great object of the practitioner, therefore, on being called on to treat a case of angina, will be to make himself acquainted with its individual character. Beginning with the early history of the disease, he will trace it to its present stage, and will endea- vour, from the narrative of the patient, and from the observation of the whole phenomena presented to him, to form a clear judgment respecting, the local condition of the organs in which the charac- teristic symptoms have their site ; and the state of all the other parts of the system, which can in any way influence these : in other words, he must en- deavour to ascertain the species or variety of angi- na, according to the distinctions formerly pointed out Are the paroxysms dependent on some structural lesion of the heart and great vessels, or are these organs in their original soundness ? If there is any deviation from the sound condition of these organs, what is the nature of this deviation ? Does structural lesion exist or not} or, if existing, can it be detected or not ? What is the actual physical condition of the heart ? Are its walls thick or thin ? Are its cavities large or small ? What is the state of the general health ? Is it such as injuriously to influence the recurrence of the paroxysms in any way, or to aggravate their severity ? If thus injuriously influencing the local disease of the heart and great vessels, is it of a kind to be remedied or mitigated by medical treat- ment ? These queries comprehend most of the subjects of inquiry which the practitioner who proceeds to treat a case of angina, must keep in view ; and although it will sometimes be impossi- ble to obtain precise information on every point, yet this will be practicable, in the greater number of cases, by care and attention, and by the employ- ment of the improved methods of investigating thoracic diseases furnished by auscultation. This latter method of exploration will, in a more par- ticular manner, aid our recognition of the physical Vol.. I.—15 ** condition of the heart ; and enable us, in a great number of cases, to determine the presence or ab- sence of organic disease in that organ. This pre- cise knowledge is, no doubt, important in assisting us to regulate our practice with the best advantage to the patient; but it is infinitely more so in ena- bling us to form an accurate prognosis respecting the event of the case. If the attacks recognise great structural lesion of the heart or aorta for their cause, we can only expect to mitigate the severity of the paroxysms, or to effect their tempo- rary removal. If there exists no structural lesion of a fatal kind, although the organs may not be of the soundest proportions, it is often practicable, not merely to mitigate or remove the paroxysms, but by great and constant vigilance on the part of the patient in avoiding the exciting causes, to pre- vent their recurrence altogether. When the dis- ease is purely one of functional disorder, a much more perfect and permanent cure may be expected. In all these cases, however, the general character of the treatment will not greatly vary. An or- ganic lesion of the heart, even of an incurable kind, can only be viewed, in relation to the treat- ment, as a predisposing cause of the attacks, just as a heart that is naturally feeble or morbidly irri- table is so ; and it is only in rare cases that the organic lesion induces the paroxysm without the aid of obvious exciting causes. No doubt, exciting causes of a much feebler kind will suffice; but the very necessity of such causes at all to produce the effect, brings the case, as far as concerns the prevention of the paroxysms, under the same cate- gory as to treatment as the purely sympathetic or nervous angina. In the case of organic disease, however, our expectations of benefit from treat- ment, and the actual results, become wonderfully less. Now, indeed, we fight not for victory, but merely to keep the enemy at bay. We, however, use the same weapons; and if we do not strive with the same enthusiasm, we must, at least, be vigilant and active ; and we shall often be re- warded with a degree of success that we scarcely dared to hope for at the commencement of our treatment. For these reasons, in the following outline of what we conceive to be the proper treatment of angina, we shall, for the most part, treat of the disease generally, and refer only to its individual forms when this becomes essential from the necessity of recommending some peculiarity of treatment. In the small number of cases in which the an- ginous paroxysm depends upon organic disease of the heart, uncomplicated with other disorders of the system of a general or local kind, our mode of treatment becomes very simple. It consists, in a great measure, in guarding against the causes which obviously excite the attacks, and in observ- ing a most cautious and rigid regimen. These measures will be more particularly noticed pre- sently, and they will be still more fully discussed in the articles which treat of certain other diseases of the heart. The remedies of a more direct and specific kind, which may influence the recurrence of the paroxysms, will also come under our notice, after we have considered the treatment best calcu- lated to reduce the more common and complex cases of angina to the state of simplicity now under consideration. The same remark will apply 114 ANGINA PECTORIS. to the cases of angina of the more purely nervous | kind, and also to those which are connected with I mere organic feebleness of the heart. The great rarity of such cases, compared with the frequency of those of a more complex kind, renders the treatment of them of comparatively little conse- quence. And there is an additional reason for not entering upon the consideration of the treatment of such cases at present namely, an apprehension lest the attention of the inexperienced reader might, in the outset, be too strongly arrested by the specific remedies applicable to them, and be thus diverted from the very different kind of ma- nagement requisite in the more complex class of cases, which, unquestionably, constitute the vast majority of those met with in practice. We must refer to other parts of this work for a detailed account of the treatment of the various disorders formerly noticed as complicating angina, or as constituting what may be termed its consti- tutional form. The presence of the anginous pa- roxysm renders scarcely any modification in the treatment necessary. On the present occasion we can only make a few general remarks on some of the most important of these complications. Of the treatment of simple or primary dyspep- sia, as co-existing with angina, we shall only here remark, that much more is to be effected by a ra- tional system of diet and regimen, both of body and mind, than by medicines; and that as a general rule, the cautious, cooling, and macerating treatment of our continental neighbours, will be found more successful than the endless ingestion of bitters and drastic purges, so much practised in this country. In many cases, no doubt, the sto- mach is simply debilitated, and requires tonics ; but it is much more frequently irritated or inflamed, and requires soothing and depletion. The prevail- ing and most injurious error among many practition- ers, is, apparently, to overlook the fact, that the stomach or intestinal canal can be inflamed without pain or the more common external marks of febrile action; or, being so, that they can be injured by the stimulus of purging. But it is in the complex constitutional disorder, which may be termed secondary dyspepsia, that these observations are most applicable. It is to be feared that the true nature of this disorder is not well understood by the generality of practitioners. It is one of those diseases which may often be said to be the oppro- bria medicorum in the worst possible sense; since it is not seldom caused, and is very frequently fixed and perpetuated by injudicious treatment. In no other disease is the over-active, or, as our neighbours term it, heroic mode of practice so pre- valent in England, productive of such evil effects; and in none is that mild, simple, yet comprehen- sive system of treatment, which embraces the whole of the disordered organs and functions, and rather prompts nature to act rightly than super- sedes her agency, so strikingly beneficial. (See Dyspepsia.) In the very numerous class of cases in which a plethoric state of the system co-exists with angina, and in many of which there is either actual gout or the gouty diathesis, the chief indications will be, first, to relieve the overloaded vessels; and, secondly, to prevent their repletion. Here the j most obvious and immediate remedy is venesec- j tion. This may, in most cases, be beneficially employed as a means of temporary relief, and will advantageously be combined with the use of pur- gatives, colchicum, &c; but the cure of the dis- ease, if it is curable, or its effectual relief, must depend on measures of more permanent operation. These are much more dietetical than medicinal. In the kind of cases now under consideration, and, indeed, in the great majority of all the cases of angina, a most strict regimen, and as low a diet as is consistent with the maintenance of healthy function, is absolutely necessary. It is not to be inferred from this, that the complete abandonment of animal food by the patient is recommended. This probably may be necessary partially, or for a time, but not generally. All that is essential to be kept in view is that the diet be of such a kind as not to be too nutritive, or to occasion fulness. In many persons, more particularly of the class whose cases we are now considering, an exclu- sively vegetable diet will prove injurious, by pro- ducing disorder of the stomach. And it is always to be kept in mind, in treating such cases, that it is almost of as much consequence to avoid local morbid irritation of this organ as to obviate ple- thora. We think, however, that a case can hardly occur in which it will not be proper to limit the< patient to the milder kinds of animal food, and to a very moderate proportion of this; the great bulk of the nutriment being farinaceous. In certain cases, a small portion of wine may be allowed; but it will scarcely ever be proper to permit it to be taken in considerable quantity; and malt liquor must be at once and for ever abandoned, in all forms and proportions. In certain of the more violent forms of organic angina, it may sometimes be advisable to attempt the relief of the disease by a systematic reduction of nutriment below the actual wants of the system, as practised by Val- salva ; and we do not doubt that, if the selection of cases for the experiment were good, and phy- sicians and patients could be found endowed with sufficient faith and courage to enforce and undergo the trial, the very best results might occasionally be obtained. But it must be confessed that such a mode of practice is but ill suited both to the weakness of humanity and the uncertainty of the healing art It is in the class of cases now under considera- tion that counter-irritants are most indicated; more particularly if the plethora is complicated with the predisposition to gout, or with actual gout And, certainly, of all the various remedies that have been used in angina, none seem to have been, on the whole, attended with more success than this class of agents. As a general rule, it may be observed that counter-irritation is much more beneficial in those diseases in which there existed, previously to the local affection, a well-marked disorder of the system at large, than in cases of pure inflammat.on produced by accidental causes in a system otherwise healthy. In the former case, the artificial irritation and discharge frequently produce relief to the system analogous in kind, however inferior in degree, to that which always attends the supervention of a spontaneous local inflammation in such cases; while the institution of an artificial inflammation in the other class of cases, has frequently no other effect than that of ANGINA PECTORIS. 115 adding to the existing disorder and distress. Dr. Smyth, of Dublin, so far back as 1770, employed issues in several cases of angina with marked benefit, and, in two at least, with perfect success ; in a third case, the disease seems to have been removed by an issue of nature's own making, viz. by a hemorrhoidal discharge, first of blood, and then of pus. Dr. Macbride, who relates these cases, expressly states that one of these patients had a strong gouty taint (Edin. Med. Coinm. vol. v. p. 12.) In Dr. Smyth's cases, the issues were applied to the thighs ; and the same practice was adopted by Darwin with equal success. "Four patients (says this author) I have now in my recollection, all of whom I believed to labour under angina pectoris in a great degree, which all have recovered, and have continued well three or four years, by the use, as I believe, of issues on the inside of each thigh ; which were at first large enough to contain two peas each, and afterwards but one. They took besides some slight antimonial medicine for a while, and were reduced to half the quantity or strength of their usual potation of fermented liquor." (Zoonomia, vol. iv. p. 43.) The reader will understand the importance of the restriction of the diet mentioned in this case. Irritants applied directly on the cardiac region have been occasionally followed by no less fortu- nate results. In cases related by Goodwin, (Med. and Phys. Journ. vi. 320.) Kriegelstein, (Hufe- land's Journ. B. xix. St. 4, p. 131.) Lind, (Med. Chir. Rev. JV. S. iv. 497.) and others, a cure appears to have been effected by the application of antimonial irritants to the chest; and, in Dr. Parr's case, great temporary relief followed the application of a blister to the same part. (Blackall on Dropsy, 365.) In a case noticed by Joseph Frank, great benefit, " conspicuum Ievamen," resulted from the insertion of an issue between the ribs in the cardiac region. (Med. Univ. Praecept P. ii. vol. i. p. 269.) Two of Dr. Blackall's cases are very much in favour of this practice, although only offering analogical evidence of its efficacy. The subject of one of them, a gentleman who had never for a single week been free from attacks of angina for ten years together, lost every vestige of it for the last nine years of his life, during which he suffered from ulcers of the lower extre- mities. In another, a gouty subject, instantaneous relief during the paroxysm was more than once afforded by the application to the feet of " mustard cataplasms, quickened with oil of turpentine." (Loc. Cit. 409.) But it is not as isolated means, used empirically, that counter-irritants, or any other topical treatment, can be expected to pro- duce their full measure of benefit; it is only when had recourse to as parts of a comprehensive system of treatment, embracing the whole disease, that they can be used with much prospect of suc- cess, or, indeed, that they should be used at all. When their application is so regulated, both rea- son and experience counsel the measure in every case of obstinacy or great severity. A most important part of the treatment of an- gina is the avoidance of the exciting causes of the paroxysms. By rigid adherence to the proper regimen, and by constant vigilance on the part of the patient to eschew everything calculated imme- diately to induce a paroxysm, very much may be effected, even in the most hopeless cases, to alle- viate suffering, and in mere functional angina a cure may very generally be expected. In all cases the patient should be so far instructed in the nature of his complaint, as to be made aware that whatever tends to hurry the circulation beyond the medium standard, is likely to induce a parox- ysm, and he must have pointed out to him all the circumstances that are. capable of producing this effect. He himself will, indeed, have learned, by sad experience, the chief of these circumstances, and will require no admonition to induce him to avoid them ; but there may be others, of the power of which he is not sufficiently aware, which may, nevertheless, be exerting a baneful influence over his malady. Some patients have been so bold as to endea- vour to master their paroxysms by persevering in the very acts which had induced them ;* and in some few cases the attempt has certainly been unattended with any bad effects, if it was not pro- ductive of good. These cases, however, were of the slighter kind ; and there cannot be a doubt that, in every case, all such attempts are to be forbidden. All strong exercises, and more par- j ticularly walking up hill or up stairs, and, in a word, every species of bodily movement that is found to induce the paroxyms, must be abandoned as far as possible. Of this kind may be particu- larly noticed the act of stooping, as in tying the shoe-strings ; drawing on boots ; straining at stool; climbing a high bed, &c. &c. Those posi- tions of the body which tend to lessen the cavity of the chest or abdomen, give double power to all contemporaneous movements that accelerate the circulation, and are therefore to be particularly avoided. It is chiefly on this account that a full meal greatly increases the bad effects of exercise ; although, in this case, no doubt, the fresh stimulus imparted to the circulation by the recent aliment co-operates. In regulating and limiting bodily exercise, how- ever, great care must be taken not to carry our precautions too far; as insufficiency of muscular motion, by inducing morbid irritability of the ner- vous system, may operate almost as unfavourably as over-exertion. In all chronic nervous diseases, — and angina, even when depending on organic causes, must, in one respect, be considered as a nervous disease,—there is no species of treatment so beneficial as regular bodily exercise ; insomuch that, in the practice of medicine, we are almost justified in considering the nervous and muscular systems as antagonist powers : the more the one is exercised, the less irritable and excitable the other becomes. Accordingly, in sympathetic an- gina and the numerous analogous nervous affec- tions of the heart, we have invariably found the greatest benefit from a regular system of exercise, conjointly with other means calculated to restore * A remarkable example of this occurred to the writer of the present article, while transcribing it for the press, in the person of a gigantic farmer, who seemed to fancy he ought to rule diseases as he ruled his team. When the paroxysms attacked him on horseback, he would throw the reins on his hois.-'s neck, put him to a canter, and bear his agony till he could sit no longer! When fairly beaten he came to the doctor, but it was too late; he died suddenly during the night, not more than eight days after his first visit. I 116 ANGINA PECTORIS. the different functions disordered. And even in the organic angina, such exercise as can be borne must be strictly enjoined. If, from experience of the ill effects of his ordinary exercise, the patient has renounced all exercise, he must endeavour to renew the practice, beginning with the gentlest, both in kind and degree. By patiently persever- ing in this plan, he will often succeed in bringing the system to bear considerable exertions without augmenting either the frequency or severity of the paroxysms. That kind of exercise which is borne best, will, of course, be most used; but merely passive exercise will jiot produce all the effects we could desire. The muscles of locomotion must be kept in action. Riding on horseback, or walking, must therefore be enforced, as far as may be prac- ticable or justifiable; and great care on the part of the patient, in avoiding all unnecessary trials of his powers, will often enable him to enjoy both these modes of exercise to a considerable extent. In walking, which is, on the whole, by much the best mode of exercise, the patient must, strictly confine himself to level ground, and must not face the wind. For these reasons, the nature of the place of residence becomes frequently a matter of much consequence. If we are justified in send- ing other patients with chronic diseases from their homes, for the sake of a difference in the climate, we are warranted in doing the same, in the case of anginous patients, in order that they may obtain the advantage of a flat country, or sheltered walks. Change of air, indeed, in the usual sense of that phrase, is very beneficial in many cases of angina; but whenever this is recommended, the configu- ration of the surface of the new locality, and its degree of shelter from winds, must be considered as much as the nature of the climate. Occasion- ally we meet with instances in which hardly any degree or form of exercise can be borne ; the wretched sufferer being reduced, through the ever- present terror of a paroxysm, to a state of almost vegetable immobility. In such cases it will gene- rally be found that the only succedaneum for the exercise that can no longer be taken, is a system of diet so rigid as to approach the limits of starva- tion ; and if the patient has sufficient courage to pursue this course, a greater relaxation from suf- fering may still be obtained than could have been anticipated. A most important chapter in the history of all diseases immediately connected with the functions of the heart, is that which treats of their relation to mental impressions; and in no case is the con- sideration of this relation so important as in the prophylaxis of angina. Two varieties of mental affections act powerfully on the functions of the heart,—the depressing and the exciting passions. It may be difficult to prove that anxiety, care, grief, or any other form of mental distress, does ever of iflself and directly produce disease of the heart ; because such states of mind, if continued, are followed by various other bodily disorders which powerfully co-operate in deranging the functions, and eventually the structure of this organ. But no one who has lived in the bustle of life, and seen much practice, will doubt for a moment that the mental states now referred to are among the most prevalent and most influential of the remote causes of such diseases. When, angina already exists, it must be admitted that these, as well as the exciting passions, are among the most frequent exciting causes of the paroxysm. The result of the operation of both classes of emotion is the same, although somewhat differently brought about; namely, an accumulation of blood in the heart disproportioned to its powers of propulsion. It is doubtful which of these causes is the most powerful. The exciting passions are usually con- sidered as such ; but it is probable that this opin- ion may have taken its rise from their more osten- I tatious nature. Anger is a social and public pas- sion ; it is clamorous, and will be both seen and 1 heard. Grief is retired, silent, and secret; it is more conspicuous in its effects than in its work- ing. Anger is, no doubt, also quicker in its ope- ration than sorrow ; and the open and instanta- neous manifestation of its power in diseases of the heart has procured for it a greater reputation than has fallen to the lot of its less obtrusive but still more formidable sister. Very many examples of sudden death from anger, in diseases of the heart, are recorded ; and not a few of these have occurred in cases of angina. These statements prove the great importance of mental discipline in this disease; and although " herein the patient must minister to himself," it is the duty of the physician to point out to him the necessity no less of the moral than of the physical means of prophylaxis. It will be remarked that, in the preceding ob- servations, we have taken no notice of specific remedies for the relief or cure of ansrina. The consideration of these has been purposely deferred until now, with the view of impressing upon the mind of the reader the much greater importance of those plans of treatment, which have reference to some obvious or intelligible disorder of the sys- tem. When no such disorder exists, or when, I having existed, it has been removed, or, at least, has been attempted to be removed by every ra- tional means which medical science affords, then, and not till then, are we justified in making trial I of that class of remedies of whose mode of ope- , ration we are ignorant and which have been de- | nominated specific*. In certain cases, means of this kind have certainly had excellent effects. After the ample discussion given to the more gen- eral method of treatment, we cannot here enter upon any detailed statement of these effects; much less can we attempt any explanation of their mode of action. A consideration of the various nature and numerous complications of angina, as detailed in the preceding pages, will show that remedies of this class may possibly possess very different powers and modes of action, and yet lead to the same results. Bark, iron, arsenic, nitrate , of silver, the salts of copper, zinc, and other medi- 1 cines both of the vegetable and mineral kind, have been frequently employed. In a few instances, narcotics, such as hydrocyanic acid, belladonna, &c. have been found useful. In those cases in which the paroxysms approach nearest to the purely neuralgic character, remedies of this kind J hold out the greatest prospect of success. If there is any reason to suspect a malarious origin or complication, bark, or rather quinine, will be found most efficient. In other cases steel and arsenic will deserve the preference. Of all the prepara- ANODYNES. 117 Uons of iron, the common carbonate and the sul- phate seem the most powerful in nervous diseases. The former must be given in large doses, as from a scruple to a drachm, several times a day. When the stomach and general system were in a proper state for their reception, we have found these medicines frequently of much benefit in diseases of the heart, whether organic or sympathetic ; and they have often been found to mitigate, if not remove, the attacks of angina. The salts of cop- per have also been often tried; we are not, how- ever, aware of any very successful result having been obtained from their use. Arsenic and zinc have been productive of more benefit. Several cases, evidently relieved or cured by these salts, are recorded by authors. A well-marked case of angina, cured by Fowler's solution, has been pub- lished by Mr. Alexander, (Edin. Med. Comment xv. 373 ;) and another cured by white vitriol is given by Dr. Perkins, (Mem. Med. Soc, Lond. iii. 580.) The great length to which this article has already extended prevents us from entering into fuller details. The reader who has studied the pathology of angina can have no difficulty in knowing when to apply specific remedies, and which ought to have the preference. John Forbes. [ANIMAL MAGNETISM. (See Somnambu- lism.) ANIMATION, SUSPENDED. (See Asphyxia.)] ANODYNES. The word anodyne takes its origin from the Greek, a, privative, and 6&vvn, pain; and the literal meaning is, a remedy which re- moves pain. The term anodyne is often used synonymously with the terms narcotic and seda- tive ; but as these three words are all different in their strict signification, it is obviously right to confine the employment of each of them to its proper acceptation. In a work like this, an im- portant end is answered by taking up, as distinctly as possible, the subject which is suggested by the word which stands at the head of each article ; and on this account narcotics and sedatives will not be particularly mentioned in this place, al- though they are generally classed with anodynes, as remedies which produce a similar effect on the animal body. When the practitioner wishes to relieve pain, he ought to ascertain, if possible, in the first place, what is the cause of the pain. The sensation of pain seems to be essentially connected with the operation of the nervous system : it may arise, 1st, from an undue degree of pressure being made upon the nerves, or from an injury sustained by external violence : 2dly, from increased sensibil- ity in the nerves themselves ; so that the pressure of external objects, which, under ordinary circum- stances, only produces the proper sensation of touch, or as in some parts, even no sensation at all, gives origin to a painful sensation. This in- creased sensibility may be the result of many dif- j ferent causes, e.g., of morbid structure or of mor- j bid function of the brain, or of the spinal marrow, or of the nerves themselves. When this increase of sensibility occurs, pain may only be felt when external pressure is applied, and then it is denomi- nated tenderness ,■ or the pain may be felt inde- , pendently of such pressure. It is very probable that in some painful diseases there is nothing mor- bid except the function of the nerves themselves ; no organic alteration, no inflammation, being dis- coverable either before or after the death of the patient. Pain in such cases is commonly called neuralgia. It occurs sometimes in paroxysms, leaving intervals of ease more or less complete ; sometimes it is constant. Tic douloureux and the periodic face-ach are instances of this species of disease of the nerves. We know very little of the real nature of sen- sation. The opinion of Dr. Cullen, that a subtile fluid pervades the nervous system, that this fluid is thrown into motion by the application of cer- tain agents, and that thus sensation is produced, is too conjectural and vague to be adopted by any modern physiologist: the same may be said of all other known hypotheses on this subject. It must therefore clearly appear impossible to afford a sat- isfactory explanation of the real nature of the sen- sation of pain. Probably that peculiar property of the nervous system which we denominate sen- sibility, or the capability of feeling, becomes so increased, in some instances, as to produce, by itself, the sensation of pain (these would be called instances of neuralgia) ; yet in other cases the sensibility in the nerves seems to be increased and pain produced by certain appreciable changes in the condition of the part which is the seat of the pain; and this may be illustrated by what occurs in inflammation ; pain being almost the constant accompaniment of the other symptoms. On ex- amination of the different parts of the body in their natural condition after death, those which are the most sensible to the touch are found to be more plentifully supplied with blood-vessels as well as nerves ; as, for example, the ends of the fingers and the lips ; both of which parts may be considered as instruments of touch : and it ap- pears that the large supply of blood sent to them is more than sufficient for the process of nutrition. This fact, taken in connection with another, which has been a matter of frequent observation—viz., that when the flow of blood to these parts is in- terrupted, without any injury having been done to the nerves themselves, numbness to a certain extent is the consequence,—leads us to conclude that the sensibility of a nerve bears some propor- tion to the quantity of blood circulating in the capillary blood-vessels in connection with it. We should therefore expect, that when, as in the case of inflammation, a larger quantity of blood is thrown into these vessels, an increase of sensibility of the nerves would be the consequence. Many physio- logical and pathological facts might be adduced in corroboration of the opinion just stated; but enough probably has been said to answer the pre- sent purpose, which is to show that the increased sensibility of a part in inflammation depends very much on the increased determination of blood to the part inflamed. Besides external violence and increased irrita- bility of the nerves, either connected with or inde- pendent of inflammation ; inordinate contraction of the muscles, or spasm, must be mentioned among the causes of pain, and of pain, too, some- times of the severest kind. The probable expla- nation of the production of pain by spasm is 119 ANODYNES. afforded by the circumstance of the pressure which must be made upon the nerves by the contracting muscular fibre, and must give origin to excessive sensation. Of course when the nerves are ren- dered morbidly sensible by inflammation, or by any other cause, the pain from spasm will be more seveie. Many facts warrant the conclusion that, in some morbid conditions of the body, excessive sensibility of the nerves and muscular spasm often co-exist, as essential parts of the same disease. It would not be in place to inquire here whether the sentient nerves, or the nerves of muscular motion, or whether both, are those affected when pain is produced by spasm : indeed it seems to be a point which we cannot determine, and probably we should derive no practical advantage from the knowledge were we able to gam it. Pain may be alleviated or subdued, 1st, by the removal of the remote cause, such as inflamma- tion, spasm, external pressure, &c; 2dly, by the employment of remedies which reduce the degree of the sensibility of the nerves ; and, 3dly, by the employment of remedies which render the brain so torpid as not to allow the patient to feel the effect of the usual causes of pain when they exist. On the first of these heads very little need be said in this place: indeed, the general means which ought to be employed for the removal of the diseases which are attended with pain cannot be properly classed among the remedies which are strictly called anodynes, although pain, along with the other symptoms of such diseases, is removed by them ; it may however be, with propriety, re- marked, that in such diseases as inflammation and spasm, the pain may often be suspended during their continuance by the medicines which are strictly called anodynes, i. e., medicines which re- duce the sensibility of the nerves, or produce a torpor of the brain, and that it may occasionally be very desirable to administer them for that pur- pose. In spasm, indeed, the same remedies which are calculated to allay pain, will frequently also allay the inordinate action of the muscular fibre, (vide Antispasmobics ;) and in many cases of painful disease, anodynes may, by deadening the patient's feelings, prove auxiliaries to those reme- dies which are given with a more direct view to the removal of the disease itself; for as the sen- sation of pain frequently acts upon the system as a kind of irritant, so the suspension of that sen- sation by means of an anodyne, may, in many diseases of excitement, allow such diseases to come more completely under the operation of the remedies which may be administered to subdue inordinate action. In many instances too, the comfort of patients may with propriety be consult- ed, and their sufferings soothed by the employ- ment of anodynes, when they are not contra-indi- cated, in diseases of a painful nature. Besides, it is necessary, in many diseases attended with pain, to endeavour to procure sleep, and this can be only done by the suspension of pain ; for pain is a common cause of watchfulness, and for this pur- pose anodynes are frequently our only resource. The exhibition of anodynes in inflammation, however, requires the exercise of much judgment. This remark appears to be the more necessary, because the employment of some of them, espe- cially of opium and the prussic acid, has been of late strongly recommended as antiphlogistic re- medies : whether they are antiphlogistic or not is not now a question for our consideration, the pre- sent object being to guard the practitioner against their indiscriminate employment in inflammation. Pain, or tenderness, is one of the most unequivo- cal signs of the existence of inflammation, when taken in connection with its other symptoms ; and during the treatment of inflammation, when no anodynes have been employed, the continuance of the pain will often afford an indication, to the practitioner, that further active measures are ne- cessary : but it is quite certain that inflammation, in a considerable degree, may be going on while all feeling of pain is suspended by the effect of an anodyne ; so that in such a case the indication of pain will be lost, the disease may be rendered obscure, and the treatment inert Besides the reason just assigned for caution in the employment of anodynes, the stimulating quality which some of these remedies possess, ought to put the prac- titioner on his guard against the indiscriminate use of them when treating inflammation. It ap- pears better, then, for the purpose of relieving pain, to depend generally on the means calculated to lessen or remove the inflammation itself, at least in all recent and active cases : this must be considered the most judicious mode of easing the feelings of the patient; but instances are daily met with in practice, especially of chronic inflam- mation, where the suspension of pain by ano- dynes is indicated by the considerations which have already been assigned. The medicines which are strictly called ano- dynes, act either by reducing the sensibility of the nerves, or by rendering the brain so torpid that painful feelings are not noticed. It may be fairly questioned whether these medicines, when they are administered by the stomach, do not all pro- duce their effects in the same manner, by reducing the sensibility of the whole nervous system, and by thus rendering it less susceptible of feeling ;__ all of them, when carried to a sufficient extent cause the brain to become torpid, and conduce to j sleep; and therefore they are not only placed on the list of anodynes, but also on that of narcotics. It is not, however, to the production of sleep that their anodyne quality is to be solely referred, be- cause, not unfrequently, perfect ease from pain is enjoyed by a patient through their instrumentality, although the mind is as wakeful as ever. When, however, these remedies are applied locally to painful parts, the action may be entirely local; although when long applied in that manner, or applied in large quantity, they will sometimes show an effect on the brain, and it would be too much to assert positively that their action is in any case entirely local. As a morbid degree of sensibility seems some- times by itself to constitute a painful disease, the employment of anodynes may be occasionally re- quired as the principal means for the cure of such disease : for this purpose it will be generally ne- cessary to continue them for some length of time. The following is a list of anodynes which are most commonly used. Opium. Hyoscyamus niger, (Henbane.) Atropa belladonna, (Deadly nightshade.) ANTHELMINTICS. 119 Conium maculatum, (Hemlock.) Datura stramonium, (Thornapple.) Acidum hydrocyanicum, (Prussic acid.)' The doses and modes of administering these remedies will be mentioned under the article Nar- cotics. Some others also will be there noticed, which are occasionally employed as anodynes as well as narcotics ; for whatever produces torpor of the brain and sleep, must, in accordance with the views already given, be capable of alleviating pain. Certain other articles of the Materia Me- dica, besides narcotics, occasionally suspend pain, and may therefore be considered anodyne in their operation. These are the ferri subcaTbonas, cin- chona? cortex, and the arsenicuin album. It is undoubtedly true that these are efficacious reme- dies in many painful diseases ; but it is very ques- tionable whether they ever act directly on the sen- sibility of the nervous system ; they appear rather in such instances to be capable of suspending the morbid action on which the increased sensibility and pain depend, and therefore, strictly speaking, the application of the term anodyne to them does not appear proper. John Whiting. ANTHELMINTICS.—This term is applied to substances intended to destroy, and to expel from the body, intestinal worms. [The defini- tion ought also to be extended so as to embrace agents that prevent their generation. The great object, indeed, is to remove the predisposition to their generation. The anthelmintics that destroy or expel, merely remove the parasites already pre- sent in the alimentary tube ; but unless the patho- logical condition that gives occasion to their re- production is removed, the evil will constantly recur.] In order to acquire a full knowledge of the manner in which these substances operate, and of their practical utility, we ought to make ourselves familiar with the natural history of in- testinal worms ; but as this information is given under a distinct head in this work, we shall con- fine our remarks, in the present article, to the means of relieving the body from these parasitic animals. The remedies belonging to this class of the Materia Medica are various, and on this account we regard that arrangement the most useful, in a practical point of view, which refers to their mode of operation. The whole class may be conveni- ently arranged under three heads :—evacuant an- thelmintics ; specific anthelmintics ; corroborant anthelmintics. I. Evacuant anthelmintics are substances which dislodge and expel worms from the intes- tinal canal, whether by a mechanical, a chemical, or a cathartic action. 1. Among those evacuant anthelmintics which operate mechanically, we consider two prepara- tions only worthy of notice,—granulated metallic tin, and the setae of the pods of the dolichos pru- riens. Tin, stannum, appears to have been used as an anthelmintic, in combination with common salt and some other purgatives, by Paracelsus; (Opera Medico-Chemica. Liber de Prepara;io- nibus) ; and it is mentioned also by Quiiu-y, (Quincy's Pharmacop. p. 246,) as a vermifuge; but it was particularly introduced to the notice of the profession, in 1736, by Dr. Alston, (Alston's Lectures on the Mat Med. vol. i. p. 150,) who prescribed it, for the first dose, to the extent of an ounce, mixed in treacle ; for the second, which was not administered until three days after the first, half that quantity ; and then finished by giv- ing a purgative, which generally brought away the worms. It is now prescribed in much smaller doses; not more than a scruple, or at most a drachm being given for a dose ; but this is repeated three or four times a day for four or five succes- sive days, and is followed by a brisk cathartic. We have found it useful chiefly in those cases in which the ascaris lumbricoides was present Lewis and many others erroneously attribute the benefit derived from this employment of tin to the arsenic which it frequently contains ; others ascribe it to the tin being solvent in the gastric juice, and thus forming hydrogen gas, which is poisonous to the worms ; an opinion which is supposed to be sup- ported by the efficacy of the aurum musivum, sul- phuretted oxide of tin, which was formerly much employed as an anthelmintic. In France a nearly similar opinion of the poisonous nature of tin is maintained ; for wine exposed in tin vessels is prescribed as a vermifuge. One forcible argu- ment against these opinions is derived from the fact that the worms are generally voided alive; and there can be very little doubt that the benefit is derived solely from the mechanical irritation of the worms by the grains of the tin—an opinion [ which is rendered more probable by reflecting on | the manner in which lumbrici dispose themselves ' in the canal. " The dissection of one subject has shown me," says Mr. Rumsey, " that they dis- pose themselves in the most curious and tortuous form, such as I thought exactly adapted to the exertion of their muscular power against opposite sides of their cylindrical abode, resisting, by this means, the effect of the propelling motion of the 1 canal, and thus keeping their station. An illus- tration of this mode may be found in the art em- ployed by a chimney-sweeper to counteract the effects of gravitation by pressing against opposite sides of the cylinder in which he exerts his skill." (Medico-Chirurg. Trans, vol. ix. p. 401.) The irritation excited by the tin prevents them from retaining this position, and causes them to be easily expelled. The other mechanical agent well adapted for expelling the round worm, ascaris lumbricoides, is cowhage, dolichos pruriens—[mu- cuna, of the Pharmacopoeia of the United States, 1842,1—a very common anthelmintic in the West Indies. The seta on the outside of the pods are scraped off, after sheathing them by dipping the pods in syrup, and then formed into a kind of electuary, which is given in doses of one or more teaspoonfuls, early every morning, for three suc- cessive mornings ; this is followed by a brisk ca- thartic. The seta% in the same manner as the tin, wound and irritate the worms, obliging them to leave their hold on the coat of the intestine,— at least this is the usual opinion of their mode of acting. A dessert-spoonful of the electuary is given to an adult, fasting, for two successive mornings : many worms are usually evacuated after taking the second dose, particularly if the long thread worms be present. The cathartic is generally requisite to aid their expulsion, and if it consist of calomel and scammony, any ascarides 120 ANTHELMINTICS. present in the rectum are expelled at the same time. Neither the powder of tin nor the cowhage are now so generally employed as they formerly were. [The short, stiff bristles on the tube which ter- minates the coriacious and scaly involucre or cu- pula that surrounds the nut of corylus rostrata, ' beaked hazel,' have been found to possess similar virtues to those of mucuna. They may be given in the same vehicle and doses. (Amer. Journal of Pharmacy, Jan. 1843; and Dungli- son's New Remedies, 4th edit. p. 200 : Philad. 1843.)] 2. The chemical anthelmintics of this (the evacuant) division operate in two ways; either purely chemically, by dissolving the viscid mucus or slimy secretion in which the worms are in- volved ; or, besides doing so, also by stimulating the mucous membrane, and by improving the nature of the secretion, preventing the accumula- tion of the slime. Lime-water and pure alkalis may be regarded as almost simple chemical ver- mifuges ; the former is perhaps more useful, espe- cially for removing the ascarides, when it is ad- ministered as an enema. When taken into the stomach, the dose should not be less than four ounces; and it is useful to combine it either with infusion of gentian or of chamomile flowers. If the solution of the alkalis, or their carbonates, be employed, the dose should be carried to its utmost extent, beginning with small doses ; for example, from twenty to thirty minims, and gradually in- creasing the number of minims daily until two drachms or more be taken twice a day. The alkalis also may be given in bitter infusions, that of tansy for instance, and combined with some essential oil in the form of an oleo-saccharum. 3. The purgative anthelmintics have no other effect than clearing away the superabundant mu- cus, and such worms as are detached from the coats of the intestinal canal, and can be expelled in conjunction with the mucus. Amongst the saline purgatives, common salt and sulphureous waters, such as those of Harrogate, have been found most useful. The common salt combines a tonic with its purgative property [and is positively detrimental to entozoa when they are out of the body]. It may be given in doses of a scruple to an ounce dissolved in a large quantity of water, or double the quantity may be exhibited in the form of enema, when the rectum is much infested with the ascarides vermiculares. The Harrogate water, besides purging, operates as a poison to the worms by the evolution of the sulphuretted hydrogen gas which it contains. Rhubarb, scam- mony, and colocynth, [castor oil, and croton oil] operate as simple evacuants ; and, for the same reason, gamboge is sometimes employed : they are generally ordered with a view of operating as cathartics after the employment of other anthel- mintics. One of the most common of the means of expelling worms in children is to give a large dose of calomel at bed-time, and on the following morn- ing an ample dose of scammony with sulphate of potassa : a large portion of bile is thus brought down into the bowels, which aids greatly in dis- charging the mucus of the intestines. In the cases of children, indeed, active purging is borne with much less inconvenience than in those of adults; and the first object is always to effect as much as can be done by cathartics, and then to have recourse to other means. II. Specific anthelmintics are substances which destroy the worms by some poisonous principle. The Materia Medica is rich in such articles, but many of them have been overrated, and are little worthy of notice ; we shall, therefore, bring before our readers those only which experience has as- certained to be valuable. The rectified oil of tur- pentine, the best of these specifics, was introduced into practice by Dr. Fenwick, for the destruction of the tape-worm. It is usually given in doses of a fluid ounce, or an ounce and a half, which sometimes produce sickness and purging, and occasionally intoxication, but rarely tenesmus or strangury ; for in large doses its cathartic influ- ence evidently stands in the way of its absorption, and prevents, in particular, its effects on the urinary passages. In some habits large doses cause a sen- sation of chilliness and a tendency to sleep ; this has been, in some instances, partially obviated by administering the oil soon after a meal. In al- most every case treated with oil of turpentine which has come under our notice, the worm has been expelled lifeless, and of a livid hue; the poisonous quality of the oil on these parasites is therefore obvious. In a few instances we have had occasion to aid its purgative effects by castor oil, which appears to answeT extremely well; in- deed this oil has been lauded by Drs. Odier and Dunant, of Geneva, as a specific in tenia. The beneficial effect of oil of turpentine in tenia led to its employment as a remedy for the destruction of other worms. In the hands of Mr. Rumsey and others, it has been found very suc- cessful in cases of lumbrici, when given in smaller doses. To a child of about three years of age, it was given in doses of half a drachm, mixed with four drachms of thin mucilage of gum arabic, twice or three times a day ; and " continued a week, with some interruptions, within which space one hundred and twenty, mostly full grown, lum- brici were brought away."* It has also been pre- scribed in the form of enema, to the extent of half a fluid ounce sheathed with mucilage of starch, for removing the common ascarides from the rec- tum ; some caution is requisite in this mode of using it; but when it can be administered, the worms are discharged in great abundance.. [Animal oi{ Dippets oil, which is identical with the oleum cornu cervi, or oil of hartshorn of the older Pharmacopoeias, is highly extolled, by the Germans more especially, and it is unques- tionably very efficacious, even in cases of taenia; but it is exceedingly nauseous, and few stomachs can retain it. Its dose is from five to twenty minims, in molasses, for three mornings in suc- cession,— following up the last dose by a brisk cathartic. The empyreumatic oil of Chabert, made by adding one part of animal oil to three parts of oil of turpentine, leaving them to combine for four days, and then distilling three parts, has also been greatly praised as an anthelmintic. It, likewise, is very nauseous; but it is very effective, in the dose * Trans, of the Medico-Chirurg. Society of London, vol. ix. p. 403. ANTHELMINTICS. 121 of a teaspoonful, in molasses, two or three times a day.] The powerful poisonous influence of tobacco on animal life has induced some practitioners to em- ploy it as a vermifuge in cases of ascarides : it is thrown into the rectum, both in the state of in- fusion mf the dried leaf, or as smoke. In either form, the danger attending its employment is suf- ficient to cause its rejection from the list of an- thelmintics. The root of the male fern was employed as an anthelmintic as early as the time of Dioscorides : it was afterwards neglected, and occasionally re- vived, until the success of Madame Nouffler's practice, in the eighteenth century, established its reputation as a remedy for tape-worm. According to Madame Nouffler's directions, three drachms of the powdered root were given in the morning, after the patient had been prepared by the exhibi- tion of an enema on the preceding night; and two hours after the dose of the fern-root had been taken, a bolus, consisting of twelve grains of calomel, twelve of scammony, and five of gam- boge, was also administered. This practice proved frequently successful; but, with Cullen, many practitioners have attributed the benefit chiefly to the purgative ; an opinion, however, which has been shaken by the analysis of the fern-root by M. Peschier, of Geneva, who discovered in it a volatile oil to which he attributes all its activity. Thirty drops of this oil are equal to three drachms, or a full dose, of the powder : it may be given either in the form of an oleosaccharum made into an emulsion with almond mixture, or of pills made with crumb of bread. One half of this dose is given at bed-time, and the other half on the following morning, on the empty stomach ; and if it do not purge, a dose of castor oil should be given in the afternoon of the same day. The success of M. Peschier with this oil appears to have been considerable, and has been confirmed by the experience of others. In every instance the worm was voided lifeless ; whence we may infer the accuracy of the opinion, that it is this oil which acts as a poison when the powder of the fern-root is administered. [See Dunglison's New Remedies, 4th ed., p. 312 : Philad., 1843.] The bark of the geoffroya inermis, or bastard cabbage-tree of Jamaica, and the powdered roots of the Indian pink, spigelia Marylandica, have been stated to be as certain anthelmintics for the removal of lumbrici as the oil of turpentine and the male fern for that of taenia. The former was introduced to the notice of the profession by Mr. Duguid, of Jamaica,* and was much extolled by Dr. Wright, who published the botanical charac- ters of the plant (Phil. Trans, vol. Ixxviii. p. 507.) The best form of exhibiting it is that of decoction, made by boiling an ounce of the bruis- ed bark in two pints of water, down to a pint. The dose for an adult is two fluid ounces, which generally purge, producing also a slight degree of nausea ; but if cold water be drunk during its operation, violent vomiting and much fever super- vene, which, however, are quickly relieved by purging with castor oil, and the free administra- tion of warm water acidulated with a vegetable * Essays, Physical and Literary, by a Society in Edin- burgh, 8vo. 1770, vol. ii. p. 21)0. Vol. I. —16 i acid. Although the active principle of this bark is still unknown, it is very evident that it operates as a specific poison to the worms ; and this opin- ion is confirmed by the fact, that, when it is tardy' { in its operation, and requires the aid of a purga- tive, its anthelmintic effect is more decided. It is seldom employed in England. The Indian pink appears to operate in its re- cent state as a narcotic, unless it be given in doses sufficiently large to secure quickly its cathartic influence ; but in the dried state in which it is usually found in this country, its narcotic pro- perty, if it possess any in this state, is exhausted in the destruction of the worms, as we have never perceived its effects on the system of the patient. I It is administered in powder, in doses of from ten I grains to a drachm ; but as far as our experience has gone, it requires the aid of some other purga- , tive to secure its anthelmintic influence in mode- i rate doses; and the violent effects of a large dose : are too hazardous to be recommended. [It is much used in the United States as an anthelmintic. Dr. Wood, indeed, thinks that it | stands there at the head of the anthelmintics. (Dispensatory of the United States, 5th edit, p. | 682 : Philad., 1843.) It is certainly highly , esteemed by many practitioners ; but others have I equal confidence in chenopodium, and much more in oil of turpentine and its combinations. The bark of the root of pomegranate (Granati Radio's Cortex, Ph. U. S.) has been much used in taenia ; but the testimony in regard to it is dis- cordant. It is almost always given in decoction, which may be prepared with two ounces of the bark, boiled in a quart of water down to a pint and a half. Of this, the dose is two fluid ounces every half hour, until the whole is taken. (Dun- glison's New Remedies, edit, cit, p. 332 ; and his General Therapeutics and Mat. Med., i. 211 : Philad., 1843.) The seed of Chenopodium Anthelminticum— < wormseed' — chenopodium of the Pharmacopoeia of the United States — is one of the most popular anthelmintics. The common mode of prescribing it, to a child three or four years of age, is to mix one or two scruples of the powder with molasses ; administering this for threes^ nights in succession, and directing a cathartic on the following morn- ing. The distilled oil, oleum chenopodii, or worm- seed oil, is officinal in the Pharmacopoeia of the United States. It is administered in the same manner as the powder, in the dose of from four to eight drops, mixed with sugar or molasses. The wormseed of Europe is the fruit of Arte- misia Santonica, or of a variety of A. maritima.] The only other anthelmintic of this division which requires notice, is one which has been very seldom, if ever, employed in this country ; and we bring it before our readers only because we have seen its active principle, veratria, operate in expelling lumbrici, when it has been administer- ed, with another intention, in the form of wine ! of colchicum. The seeds of the veratrum saba- dilla, the substance to which we refer, have been long celebrated on the continent as a specific in taenia lata, and are much extolled by Seeliger and | M. Brewer. The latter prescribed the powdered j seeds in doses of three grains, which were taken I on an empty stomach in the morning, for eight 122 ANTHRACION —ANTIPHLOGISTIC REGIMEJN. successive days; and these, on the ninth day, were succeeded by a strong dose of gamboge and valerian. It is not easy to explain the beneficial effects of this plan of treatment without referring it to the veratria, which, besides acting as a direct poison to the worm, stimulates the gall-ducts, and, bringing a large portion of acrid bile into the duodenum, sweeps out the dead worms. In this manner we have seen the wine, and the other preparations of colchicum, operate, in expelling lumbrici; but we have had no experience of their influence in taenia. III. It only remains to notice the last division of this class of medicines, corroborant anthel- mintics. All the substances, in the first divisions, act merely upon the worms already existing in the intestines, either destroying them or expelling them in a living state; thence the necessity of adopting means for preventing their recurrence ; and as debility favours their production, it is obvi- ous that tonics are indicated. All the bitters may be employed for this purpose, but the chalybeates have with much reason been preferred. At one time it was supposed that the preparations of iron are poisonous to worms, an opinion founded upon the observation that the earth-worm dies when submersed in chalybeate solutions : but the fact that the earth-worm respires by the skin, which is not the case with intestinal worms, was over- looked ; and it is now generally admitted that the chalybeates operate as anthelmintics by their tonic influence, strengthening not only the alimentary canal, but the whole system. Among the prepa- rations of iron, the sulphate was extolled by Boerhaave, who gave it to the extent of a drachm, dissolved in a pint of water, in divided doses, within twenty-four hours. We have found the milder preparations, particularly the tartarized iron, operate more favourably with children and females, who, as we have already said, are the chief subjects of worms. After clearing the bowels with a large dose of calomel and scam- mony, we prescribe the tartarized iron, in doses of a fluid drachm of the solution, to be taken three times a day ; but the wine of iron, in simi- lar doses, or the tincture of the acetate of iron, of the Dublin Pharmacopoeia, in doses of fifteen or twenty drops, given in milk, will answer the same purpose. In cases of ascarides, chalybeate water, such as that of Tunbridge, has been found to be extremely useful when administered as an enema* A. T. Thomson. [ANTHRACION (from avOoai, < a coal'). This affection has an extensive synonymy; — Pustula maligna, Vesicula gangrscnescens, Malignant vesicle, Malignant pustule, and Persian fire. In France it is known under the names, Pustule maligne, Feu Persique, Mal-vat, Bouton malin, &c.; and in Germany under that of Milzbrandkar- bunkel. It is characterized by the appearance of a bleb filled with reddish sero-sanguinolent fluid, under which a small lenticular induration is formed, which is speedily surrounded by diffuse inflammation of an erysipelato-phlegmonous cha- racter. The inflammation terminates in gangrene, which spreads rapidly from the centre to the cir- cumference of the tumour. This is the general tbaracter of the affection; but at times a white line of demarcation checks its progress : at others, the cellular tissue becomes rapidly disorganized, and deep caverns form beneath the skin. When gangrene strikes the central part, the inflammation extends to a considerable distance around,— the skin being red, tense, and shining, and the sub- cutaneous tissue swollen, infiltrated, and often emphysematous. The affection is generally accom- panied by great constitutional disturbance ; and in its progress, the symptoms become markedly ady- namic, and the patient often sinks and dies within the first twenty-four hours from the onset. When it terminates favourably, the phenomena are the same as in cases of local gangrene in general; a line of separation occurs, and the constitutional symptoms improve. It is the common belief that anthracion occurs only from the contact of the matter of carbuncle of animals. Accordingly, it appears on parts of the body that are ordinarily or accidentally ex- posed. Thus, it is often seen on the face ; never on the scalp ; and most commonly on the hand, forearm, arm and neck. (Rochoux, Dictionnaire de Medecine, torn. 26. p. 510 : Paris, 1842.) It would seem, however, that it may originate spon- taneously in man. The treatment, where the disease is produced by the contact of virus, may be divided into that which is proper, whilst the affection is entirely local; and into that which is necessary, where the constitution becomes implicated. The plan thought to be most successful, in the first case, is to make incisions through the gan- grenous parts, so as to permit escharotics to come in contact with the sound textures, and induce in them a new action. A strong solution of nitrate of silver, from 20 to 40 grains to the ounce of water, or liquid muriate of antimony, or diluted or even strong muriatic acid, may be applied by means of dossils of lint. By some, potassa has been ad- vised ; and by others, chloride of zinc. The escharotics may remain on a few hours ; after which, turpentine dressings, or warm poultices, may be substituted. On the next day, if there be no appearance of an extension of the disease, the soothing treatment may be pursued, or poultices, to which aqua chlorini has been added; or an ointment of the same ; or a cataplasm or ointment of chlorinated lime may be used. The internal management must be the same as in gan- grenous affections in general. Tonics are de- manded ; and opiates may be needed to allay suffering. (Practice of Medicine, 2d edit. p. 113: Philad., 1844.) _ _ ' Robley Dunglison.] ANTIPHLOGISTIC REGIMEN, (fromdxri, contra, and Q\6yo>ais, inflammatio). The term antiphlogistic regimen implies the accessory treat- ment required in aid of medical discipline for the removal of fever or inflammation. So essential is this aid, that neglect of it may render fruitless the most judicious course of medical treatment on which account it merits the serious attention of every practitioner. As the medical treatment of fever and inflam- mation will be treated of under the proper heads, it is unnecessary in this article to do more than notice the assistant means by which its end may be promoted. These may be considered as they ANTIPHLOGISTIC REGIMEN. 123 regard bodily rest, diet, air, temperature, and men- tal repose, under which all that is essential may be included. Bodily rest---Fever and inflammation being characterised by morbid excitement, which, when excessive or unrestrained, is the source of much injury, and to allay which is the object of medical interference, it becomes important to avoid every influence by which it might be prolonged or ex- asperated. Bodily exertion increases excitement, and should therefore be suspended by consigning the patient," if not in every instance to bed, at least to perfect quietude. Under fever the whole muscular system becomes debilitated, and even slight exertions are not made without an effort far greater than would be required in a state of health. During such effort the motions of the heart, al- ready too frequent, become still further accele- rated ; more blood is transmitted to the lungs than can find a free passage through them, and the breathing is hurried in proportion. Such dis- turbance of the important functions of the heart and lungs is eminently unfavourable to the objects which the physician has in view. Independently of locomotion, even the erect posture is not sus- tained by a frame debilitated by febrile derange- ment without a painful effort, and is badly borne. Under febrile or inflammatory diseases requiring active treatment, therefore, it is always advisable to enjoin perfect rest and a recumbent posture, to ensure which the patient should be kept in bed in all cases where there is much excitement to allay. Diet.—This requires to be regulated both as to quantity and quality. Happily, under fever appe- tite pretty generally declines, and the patient is thus debarred from taking what would aggravate his disorder. The suggestions of nature are always worthy of attention, and in no instance are they more clearly announced than in the inappetency which attends the febrile state. In the exposition of fever and of inflammation given in this work, it will be seen how completely this disinclination for food accords with what our best knowledge of fever enjoins. During acute fever or inflamma- tion, abstinence is essential; and so long as they continue active, the standard of diet can hardly be too low. Simple diluents are all that the stomach can bear, or the patient require, and even with these the stomach should not be oppressed. So powerful is mere abstinence in abating fever, that it might almost be laid down as an axiom, the more perfect the abstinence, the less will be the necessity for medical agency. The remarks here made on the quantity of food apply with even greater force to its quality. It is familiarly known that animal food is more nutritive than vegetable; consequently animal diet must be unsuited to a state of disease in which nutritive matter is already relatively in excess. However opinions may differ on the connexion of fever with an antecedent state of plethora, all will agree that under fever the ordinary expenditure of nutritive matter in the several secretions of health becomes diminished, from the secretory functions by which the several tissues are nourished failing in their wonted ener- gies ; whence the nutriment with which the blood is,'on the accession of fever, already charged, can no longer be beneficially disposed of, and becomes oppressive to the system. To add to the load by more diet, and especially by diet so nutritive as that which animal matter furnishes, cannot be judicious. Nature revolts from it, experience condemns its use, and enlightened practice will ever withhold it, however importunate friends and relatives may be, through mistaken kindness, to induce a relaxation of that discipline which the judgment of the medical attendant leads him to enforce. According as disease declines, greater indulgence may, of course, be granted ; but this consideration belongs to the medical treatment, and is discussed elsewhere. The present article ' professes only to specify what is meant by anti- phlogistic regimen when it is enjoined by the j medical attendant. Air—The time is happily gone by when febrile patients were immured in heated chambers, over- whelmed with blankets, a good fire maintained to prevent the risk of cold, and every aperture, through which pure air could enter, even to the key-hole of the door, carefully closed. Absurd and almost incredible as this practice now appears, half a cen- tury has scarcely elapsed since it was generally followed. The febrile sufferer is now allowed to breathe a pure atmosphere, to ensure which is a most essential part of the antiphlogistic regimen. The intelligent practitioner, to whom the elements of physics should be familiar, can be at no loss to ascertain whether the circumstances of the inva- lid's chamber be such as to afford the necessary assurance of adequate ventilation. The confine- ment of air by closed bed-curtains is particularly pernicious, and should be utterly disallowed, the use of these being limited to averting direct cur- rents, and moderating the glare of light. Even light should not be wholly excluded from the sick chamber, save where there is high excitement of the brain, or morbid sensibility of vision. Temperature.—On this head it may suffice to state that the best medium temperature for a cham- ber is about 60° of Fahrenheit's thermometer. Circumstances may occasionally require it to be : higher or lower. As sensation is a very imperfect measure of temperature, the best security is to adjust the heat by a thermometer suspended in the room. Mental repose.—The observations made on bo- dily rest are all applicable to the state of the mind. Mental excitement is capable of disturbing all the bodily functions, and of exasperating every symp- tom of fever. Of ordinary exertion of mind the febrile patient is soon rendered incapable by the effects of disease, which speedily hebetate the mental energies. The morbid excitement of brain which results from its special derangement is itself a symptom of disease, and, as such, is the proper province of the medical attendant, who should direct the appropriate treatment; all ordi- nary excitement of mind of which the patient may be susceptible should be carefully restrained, or permitted only with extreme caution; perfect quiescence both of body and mind being that state which will best second the medical treatment. Indeed, it is the same principle which applies to both; for though in referring to mind the remarks are applied to the manifestations, the reasoning is really directed not to these, but to the physical state of the brain on which they depend, and 124 ANTISPASMODICS. which, under fever, is sensibly disturbed by what- ever gives rise to much mental emotion. The moral treatment of the invalid is, conse- quently, no unimportant part of antiphlogistic regimen. -,-, „ ° E. Barlow. ANTISEPTICS. See Disinfection. ANTISPASMODICS (ivrl, against, and airaa- jibs, spasm) are usually defined stimulant sub- stances which allay irregular muscular contrac- tion. In whatever manner muscular action takes place, it may be affirmed that it is altogether at- tributable to the nervous system ; the nerves of motion being those engaged in it, whether the stimulus or exciting power be mental or material. The motion which is induced is transitory, and always followed by a state of rest; it is this alter- nation of motion and quietude, under due regula- tion, which constitutes the distinction between ordinate and inordinate muscular action. If, after muscles have contracted, they retain this condition when the exciting cause ceases to operate, they are said to be in a state of spasm, and such medi- cines as have the power of resolving this state are termed antispasmodics. If narcotics allay irrita- bility, soothe pain, and produce diminished suscep- tibility to the impressions of exciting agents, it may reasonably be inquired in what respect anti- spasmodics differ from narcotics. The chief circumstance in which antispasmo- dics differ from narcotics is, that the administra- tion of the former is not followed by the insensi- bility to impressions, and collapse, which almost invariably follow the exhibition of narcotic sub- stances. No such effects can be induced by anti- spasmodics, even in large doses ; yet they are as powerful as narcotics in repressing inordinate muscular action. In explaining, therefore, the difference between antispasmodics and narcotics, we may hazard the opinion that it is probable the impression exerted on the extreme nerves by a narcotic is confined to those of sensation, and must be communicated to the brain before the effect is produced ; whereas that caused by an antispasmodic is confined to the nerves of motion, and produces an immediate and more permanent result by some changes effected in the state of the motor nerves, independent of any communication with the sensorium. If this opinion be correct, antispasmodics, in the strict meaning of the term, stand in the same relative position to narcotics as astringents to tonics. But, whatever may be their mode of action, the distinct nature of an antispas- modic, acting simply as such, is very obvious; and antispasmodics may be regarded as holding an in- termediate place between narcotics and tonics,— less diffusible but more durable than the former,— more immediate but less permanent than the lat- ter. Another point requires consideration, viz., whether antispasmodics are to be regarded as sti- mulants or sedatives ? If our hypothesis be cor. rect, they have a sedative operation ; for if the irregular or inordinate action, which they over- come, be the consequence of irritation, either men- tal or corporeal, it follows that, in resolving spasm, the susceptibility of impression in the extremities of the motor nerves must be diminished, and this can only be the result of a sedative power. It may, however, be affirmed mat this may be either immediate, or the consequence of a previous stimu. lant operation : thence, we can explain the reason why some of these medicines which are direct antispasmodics stimulate the general system, and consequently quicken the pulse ; since, ike nar- cotics, their primary action may be stimulant, and quickly followed by collapse. According to this mode of reasoning, the same results may follow from the influence of the exclusive operation of antispasmodics on the nerves of motion, as from that of narcotics on those of sensation. Antispasmodics, as far as regards their mode of action, may be divided into direct, or " those which exert their influence on the nervous energy, but neither as narcotics or tonics ;" and indirect, or «those narcotics and tonics which produce an an- tispasmodic effect." The effects of antispasmodics are generally per- ceptible very soon after their administration, more especially if the powers of the individual are weak. It should, however, be kept in mind that this class of remedies is of no avail, indeed is posi- tively injurious when the spasmodic muscular ac- tion is the consequence of inflammation of the brain or spinal marrow : under such circum- stances, blood-letting and other measures calcula- ted to subdue the primary disease, are the proper measures to be adopted. It is necessary also to mention that the operation of antispasmodics is very transient, and that by frequent repetition their influence on the nervous system is much impaired; the dose therefore requires to be modified very much, according as the individual has or has not been accustomed to their employment. The Materia Medica furnishes few direct anti- spasmodics. One of the most powerful, musk, is too expensive to be generally prescribed, particu- larly as the dose is required to be very large in order to obtain a satisfactory result from its em- ployment. We can bear testimony to its power- ful influence in diminishing the violence of the paroxysms of idiopathic epilepsy, and greatly lengthening the intervals, when the dose is carried to the extent of a drachm given at intervals of eight hours. It is most advantageously prescribed in the form of bolus : the mixture and the tinc- ture of the Pharmacopoeias being very uncertain j preparations. Much less can be said in favour of castor, which is greatly inferior to musk as an antispasmodic. Among the animal oils, that of Dippel, although much lauded on the continent, and notwithstand- ing its success in epilepsy in the hands of Alibert, may be regarded as an antispasmodic of little effi- cacy, and ought to be expunged from the list of Materia Medica. The oil of amber, also, formerly prized as a powerful antispasmodic, is now scarcely ever prescribed. Valerian, assafoetida, galbanum, and sagapenum, owe their antispasmodic properties chiefly to volatile oil, in combination with resin and extractive matter : their efficacy in hysteria, spasmodic asthma, and similar affections, has been well ascertained. Naphtha was formerly much employed as an antispasmodic in diseases unat- tended with inflammatory symptoms ; and the West Indian practitioners still extol it in hooping- cough, and some other spasmodic diseases. | With respect to indirect antispasmodics, little is , required to be said. In selecting them, we must ANTISPASMODICS. 125 be guided by the state of the patient and the nature of the exciting causes of the spasms which we are called upon to relieve. If they are the result of local irritation, and kept up by habit after the removal of the irritating cause, narcotics are to be employed as the most powerful means of allaying irritation, and breaking the habit which has been acquired. But if the spasm is maintain- ed by a peculiar susceptibility to impressions, which is always, more or less, connected with debility, then tonics are to be administered ; and the more rapidly the body can be brought under their influence, the better. Something may be expected to be said with re- gard to mental impressions as antispasmodics. There can be no doubt that some mental states produce and maintain spasmodic action in the body, while others as readily operate as powerful antispasmodics. As a minute consideration of this question, however interesting in itself, would exceed our limits, we shall merely allude to the power of abstraction. In every instance of spas- modic action, from whatever cause, the attention is directed to the part affected ; so long as this exists, no corporeal agents which do not make a greater impression on the mind than that pro- duced by the spasm, can resolve it : but when the attention is withdrawn from the spasm, it is in- stantaneously relaxed. Thus, a man has his shoulder-joint luxated ; and, after various attempts, the luxation cannot be reduced on account of spasm which has supervened, and which is main- tained by the attention of the patient being direct- ed solely to the part; but abstract the attention, and the spasm instantly yields, and the head of the humerus slips into the socket. In the same manner, and with the same success, the antispas- modic influence of abstraction has been experi- enced in hernia and other diseases ; in its appli- cation, however, great judgment and nice discri- mination are requisite. In reference to the practical employment of antispasmodics, their utility is confined to one order of diseases only, the spasmi. In tetanus, the narcotic antispasmodics, particularly opium and camphor, have been much employed; but neither these nor the direct antispasmodics, musk, oil of amber, or assafcetida, have fulfilled the anticipations of practitioners. The most power- ful is, undoubtedly, opium ; and it is almost in- credible what doses of this remedy may be ad- ministered in this disease; fifteen and twenty grains have been given every three hours, for eight and ten days successively, with little effect upon either the disease or the constitution of the patient When opium has proved beneficial, its effects have been rarely obvious until after the tenth or twelfth day of its exhibition ; but indeed we may safely affirm that little reliance is to be placed upon the influence of the most powerful antispasmodics, direct or indirect, in this disease. [The Cannabis Indica or Indian Hemp has been recommended, by Dr. O'Shaughnessy, of Calcutta, as an " anti-convulsive remedy" of the greatest value ; and when given boldly, and in large doses] as a successful remedy in traumatic tetanus. (Pereira, Elements of Mat. Med., 2d edit. p. 1096: Lond. 1842 ; and Dunglison's New Remedies, 4th edit. p. 133 : Philad., 1643.)] In chorea, when purgatives have failed to pro- cure relief, antispasmodics, such as musk, opium, and belladonna, have been freely administered ; but in this disease more decided benefit has been obtained from tonics operating as antispasmodics than from either narcotics or musk. Much ad- vantage has resulted from the use of the nitrate of silver, the carbonate of iron, and arsenious acid ; all of which operate as indirect antispas- modics. It is true, that, in some cases in which these tonics have failed, the disease has yielded to the use of musk and camphor; but, in general, less advantage has been derived from the employ- ment of direct antispasmodics, than, from the nature of the disease, might have been reasonably anticipated. Antispasmodics effect little good in epilepsy. Some of the narcotics have sometimes appeared to prove useful; but we have seen them all fre- quently fail in relieving this disease. Among the indirect antispasmodics, the preparations of zinc, copper, mercury, and arsenic, have each had a transitory reputation ; but if any of the metallic tonics merit confidence, it is the nitrate of silver, which operates by diminishing the susceptibility to those impressions that produce irregular action. In asthma, at least in one form of it, antispas- modics have been found highly beneficial. Assa- fcetida among the direct, and opium and stra- monium among the indirect antispasmodics, have been found capable of accomplishing every thing to be expected from this order of remedies in that affection. It is singular that in this country opium should not have been smoked, in the manner in which the Chinese employ it, for the relief of spasmodic asthma; as the same circumstances which render stramonium serviceable when smoked are likely to render opium still more so ; and the experiment is worthy of being tried. In hooping-cough, the direct antispasmodics have been little employed; but some of the indirect, for example, belladonna and conium, are much to be relied upon. Our experience in the use of the extract of belladonna enables us to offer the fol- lowing directions for its administration. Sup- posing a child of five years of age to be the ob- ject of hooping-cough,— after administering an emetic and purgative, a pill containing one-tenth of a grain of" extract of belladonna may be given every fifth hour; and the dose gradually increas- ed, until the sight be affected, and a scarlet efflo- rescence closely resembling the eruption of scar- latina appears on the skin. Whilst this state continues, the cough is often suspended ; and by maintaining it for some time, both the violence of the paroxysms is abated, and the continuance of the disease greatly shortened. The adjunct which we have found most beneficial is the hydro- cyanic acid, in doses of one minim, administered in any convenient vehicle ; but it should be gen- erally known that the efficacy of the extract is destroyed by alkaline solutions.* In colic, the benefit to be expected from anti- spasmodics depends much upon the exciting causes of the attack. In simple constriction of the in- testines, narcotics will answer every indication intended to be fulfilled ; but when flatulence is * A fact ascertained by Professor Runge. Ann. de Chimie, loin, xxvii. p. 3-2. 126 AORTA, (ANEU RISM OF THE) the exciting cause of the spasmodic constriction, nssafoetida and the direct antispasmodics will be found serviceable; and, when there is constipa- tion, calomel and aperients must be joined to the antispasmodics. Opium, in such cases, tends rather to augment than to impede the operation of purgatives, although the extract of hyoscyamus is frequently preferred. In no disease have antispasmodics more satis- fied the anticipations of the practitioner than in hysteria. [It is the only disease, in which, at the present day, direct antispasmodics are much used.] In this affection the convulsions are of the most severe description. During the paroxysm, the direct antispasmodics, especially assafcetida and valerian, have been found very useful, when pre- scribed in sufficient doses, which is rarely the case; for, as we have already said, little benefit can be expected unless the doses be much larger than those usually prescribed. During the inter- vals, the metallic tonics should be chiefly relied upon as antispasmodics ; and, indeed, it is only by endeavouring to correct the morbid susceptibi- lity existing in these cases that any permanent benefit can be expected. Upon the whole, the range of the order of anti- spasmodics is extremely circumscribed ; at best, the different substances can be regarded as auxi- liaries only. Spasm is to be regarded rather as the result of causes which are to be removed, than as a' circumstance for which remedies are to be directly administered. [It would seem, that all the direct — and such only can be esteemed true antispasmodics—must produce their effect by virtue of the new impres- sion which they make on the olfactory and gus- tatory, or on the gastric nerves, or on both ; thus deriving from the inordinate action in some other part of the nervous system. All the direct anti- spasmodics are, indeed, well calculated to effect this derivation. Most of them, as assafcetida, castor, Dippel's oil, valerian, and skunk-cabbage, being exceedingly offensive, and at the same time possessed of excitant properties. In ordinary cases of spasm, not dependent upon an excited state of vessels, anything, therefore, that will pro- duce a new nervous impression may prove anti- spasmodic. Narcotics do so by blunting the impressibility of the nervous system ; nauseous agents produce their effects upon the olfactory or gustatory nerves ; and, if they be excitants at the same time, upon the nerves of the stomach. Cer- tain highly nervous and imaginative persons can feel pains wherever they please ; and many an individual, by the perusal of cases of disease, has fancied himself affected with the same sufferings which he has seen depicted. If, therefore, atten- tion can direct the nervous afflux to a part, it is obviously of great moment so to impress the ner- vous system of the individual, that no concentra- tion of the kind may take place towards the suf- fering organ ; and this may be effected by engaging the mind, in light cases, on some subject of enter- tainment or reflection; in stronger cases, by im- pressing the totality of the nervous system, as by narcotics; or by affecting nerves at a distance from those implicated, as by the direct antispas- modics more especially. (Dunglison's General Therapeutics and Materia Medica, i. 396: Philad. 1843.)] A t. Thomson. AORTA, anf.crism of the. The aorta, in common with the other arteries of the body, is liable to aneurismal disease, the anatomical characters of which are comprehended under the four fol- lowing varieties : — 1st.—Dilatation, which is an enlargement of the whole circumference of the artery. 2d.__True aneurism, which is a sacculated dilatation of a portion only of the circumference, or of one side of the artery., 3d. — False aneurism, which is formed by ulceration or rupture of the internal and middle coats, and expansion of the external or cellular into a sac. It is called primitive, when all the coats are directly divided, as by a wound ; and consecutive, when it is consequent on ulceration or rupture of the internal and middle coats. 4th. — Mixed aneurism, which is a superven- tion of false upon true aneurism, or upon dilata- tion ; that is, after dilatation, either partial or gen- eral, of all the three coats, the internal and middle burst, and the external alone expands into a fur- ther sac, surmounting the original dilatation or true aneurism. Formation and anatomical characters of the several species of aneurism. 1st Dilatation, or enlargement of the whole circumference of the Aorta*—When the coats of the aorta, whether from inflammation or from any other morbid action, have become diseased, they lose their elasticity, a quality which resides principally in the middle tunic. As fluids press equally in every direction, the blood pro- pelled by each contraction of the heart into the aorta, exerts not only a longitudinal, but a lateral force, which expands the vessel, and constantly tends to enlarge its caliber. The elasticity of the arterial walls enables the vessel to resist this ex- pansive force, and to regain its previous caliber after the diastole. Consequently, when the elas- ticity is impaired or lost, the vessel, not being able to regain its original dimensions after each diastole, becomes permanently dilated ; and this takes place to a greater or less extent, and with greater or less promptitude, in direct proportion to the predominance of the distending over the resisting force. It very rarely happens that a dilated aorta does not present, in its interior, some of the morbid changes already described, (see Arteritis); namely, cartilaginous, steatomatous, atheromat- ous, or calcareous depositions, with a thickened, wrinkled, and fragile state of the internal coat. When such depositions are not apparent, the walls, according to our observations, are always more or less indurated, opaque, and inelastic ; and are sometimes extenuated, particularly the middle coat, and sometimes thickened, with a softened and easily separable state of the internal coat: a condition of parts which is a much more natural cause of dilatation than paralysis of the middle coat, supposed by some authors to be its cause when no depositions were manifest. The ascending portion, and arch of the aorta, particularly the latter, are by far the most frequent AORTA, (ANEURISM OF THE) 127 ■eats of dilatation ; but the descending portion, both in the chest and abdomen, is sometimes affected, and the dilatation is then either uniform throughout the whole length of the vessel, or it consists of one or even a series of ovoid or fusi- form expansions. The side of the artery adhe- rent to the spine, and the lesser curvature of the arch, yield less readily than the other parts. Dila- tation of the aorta does not, in general, exceed twice the natural caliber of the vessel, but we have occasionally seen it attain three, or even four times that size. When such is the case, it fre- quently presents many minor bulgings or pouches, which give it a considerable resemblance to the transverse arch of the colon. The walls of these pouches are often extenuated and semi-transparent from horn-like and calcareous depositions, and it is here more especially that mixed aneurism is apt to take place; for the brittleness of deposi- tions causes rupture of the internal and middle coats, and the engraftment of false aneurism upon the true. Dilatation of the pulmonary artery is extremely rare. We have met with one remarkable case in which it was enlarged to four inches and a half in circumference. Dilatations, even though pouch- ed, scarcely ever contain laminated coagula; for the surface is, in general, too smooth to arrest the blood. When they do take place, it is in conse- quence of an ulcerated or fissured state of the internal membrane, which forms nuclei for the adhesion of fibrine.* The coagula thus formed occasionally fill up the whole of the dilated por- tion, and leave the canal of the artery of its natural caliber. The great arterial trunks rising at right angles from the aorta, as the innominata and cceliac, gen- erally participate in the dilatation : the left subcla- vian almost always remains exempt; without doubt, says Laennec, on account of the acute an- gle at which it branches off. Dilatation takes place not only in the aorta and its immediate trunks, but sometimes in smaller and more remote arteries, as, for example, the carotid by the side of the sella turcica, the temporal -j- and emulgent i with their ramifications, the arteries of the extre- mities, and those feeding tumours of any descrip- tion, particularly fungus hajmatodes and the he- morrhagic najvus or aneurism by anastomosis of John Bell. 2d. Trne Aneurism, or lateral partial dilatation of the Aorta.—True aneurism dif- fers from dilatation in the circumstances, that it is an enlargement of a limited portion only of the circumference of the aorta ; that it generally rises with an abrupt margin; and that its neck is, in most cases, narrower than the body of the sac. Its formation is to be attributed to a loss of elasti- city, and, consequently, of resistance, in the par- ticular part only that dilates; and the proofs of its existence consist in the possibility of tracing the internal and middle coats of the artery throughout the whole extent of the expansion, and in the presence within the sac of those morbid appear- * Bums, on Diseases of Hie Heart, p. 206. Bertin and Bouillaud. Cum: xxxvi. t Cruveilhier Essai sur l'Anat. Patholog. Pans, 181o, '"journal de Medecine par MM. Corvisart, Leroux.et Boyer, torn. vii. p. 255. ances which are peculiar to the internal coats of arteries, such as calcareous, cartilaginous, and atheromatous depositions, with slight fissures, and small red spots. These proofs have, of late years, been so frequently verified by dissection, that the reality of aneurism by dilatation of all the coats of an artery is no longer problematical. Almost all the aneurisms of the ascending portion and arch are originally of the true species, but the false is sometimes engrafted upon them. The tumour generally springs from the anterior or the lateral part of the vessel, while the posterior part is little, if at all implicated : it sometimes attains the magnitude of a mature foetal heart, § and gen- erally inclines to the right side of the chest When it springs from the root of the aorta, and the middle and internal coats happen to burst, there results, not a false aneurism surrounding the true, as in other parts, but a fatal extravasation into the pericardium. The reason of this is, that the part of the aorta referred to is destitute of the cellular tunic, and the pericardium which supplies its place, not being equally extensible, bursts, ra- ther than dilates into a false aneurism. In the same way the deficiency of the cellular coat in the arteries of the brain causes their rupture to be fol- lowed by an apoplectic extravasation, instead of by the formation of an aneurismal sac. It has been stated by a recent writer that a preparation in Mr. Hunter's collection subverts the doctrine that false aneurism does not form at the root of the aorta. The preparation of which he speaks, however, is not one of false aneurism, as the mid- dle coat is perfect, the internal one alone being diseased, or removed, (it is doubtful which,) at the base of the sac. It has not been denied by authors that true aneurism may form at the root of the aorta. We have ourselves seen it in more than one instance. Coagula are occasionally, but not often, found in true aneurisms; they are usually in masses, adherent by a peduncle, and seldom in layers investing the walls unless the aneurism is very large ; the reason of which is, that the mouth of the sac being in general spacious, the blood has a sufficiently free ingress and egress to circu- late with force, while the surface of the sac is so smooth as not to arrest the fibrine, and cause its deposition in layers. But when the circulation is by any cause enfeebled, the blood stagnates and forms coagula in masses, which become adherent by limited portions or peduncles. True aneurism is much more rare than either false aneurism or dilatation. 3d. False Aneurism, or Aneurism hy ul- ceration of the internal or middle Coats* —Nichols proved, by experiments made before the Royal Society of London, that, when the internal and middle coats of an artery are divided, and water or air is forced into the vessel, the external coat distends so as to form a small sac, (Philos. Trans, vol. xxxv. p. 443.) In the same manner, when the internal and middle coats are perforated by ulceration or a fissure, the blood, by its lateral pressure, gradually raises the external coat, and expands it into a sac, which communicates with the interior of the artery, whose caliber is not en- § Corvisart, Journal de Medecine, par MM. Corvisart, Leroux, et Boyer, t. vii. p. 355. Laennec de I'Aiisrult. t. ii. p. 091. 128 AORTA, (ANEURISM OF THE) larged, by a narrow aperture or neck. As the dis- tension proceeds, the external coat itself gives way, and the sheath of the vessel next opposes the effu- sion of blood ; finally, when this also yields, the contiguous parts, whatever be their texture, con- tribute to the formation of the sac, they having previously undergone thickening and agglutina- tion by chronic adhesive inflammation, to which distension had given rise. Such is the manner in which the sac is formed in aneurism from ulce- ration of the arterial coats. It presents no vestige of the middle or fibrous coat, nor the depositions connected with the internal membrane; but its inner surface is extremely rugged and unequal from lymph irregularly deposited by inflammation. To this rugged surface adhere the layers of fibrine subsequently deposited by the blood. Perforation of the internal and middle coats is not always followed by aneurism of the kind de- scribed. Laennec met with a case in which the internal and middle coat had been divided by a narrow transverse fissure extending over two- thirds of the circumference of the artery ; and the blood, instead of distending the external coat into a sac, had insinuated itself between it and the fibrous, and dissected them from each other over upwards of half the circumference of the artery, from the arch of the aorta to the common iliacs, (De PAuscult torn. ii. p. 700.) Fissures of the kind described result from cracks or lacerations occasioned by calcareous depositions ; but the case of Laennec, and two similar cases mentioned by Mr. Guthrie, (Guthrie on the Diseases of Arte- ries, p. 40 and p. 43,) are the only instances within our knowledge in which a fissure has been follow- ed by more than a circumscribed effusion of blood around it, occasioning a slight swelling of the external coat. Nichols found this in the body of George II., (Philos. Trans, vol. lii. p. 269 ;) and Hodgson once met with it, (On Diseases of Arte- ries, p. 63.) The late Mr. Shekelton has described, in the Dublin Hospital Reports, vol. iii., another and previously unnoticed kind of aneurism ; namely, the blood had forced its way through the internal and middle coats, dissected the middle from the external or cellular for the space of four inches, and then burst again through the internal and middle coats into the canal of the artery ; thus forming a new channel, which eventually super- seded the old one ; the latter having become oblit- erated by the pressure of the tumour. [The term Dissecting Aneurism was given by Laennec to this form. Many such cases are now on record. Dr. Pennock (Amer. edit, of Hope on Diseases of the Heart, p. 408, Philad. 1842,) refers to four that have occurred in the observation of American pathologists. In all these, the lesion was identical; — the separation of the laminae of the middle coat, by blood driven by the propulsive force of the heart through a rent caused by a laceration of the serous coat, and a partial rupture of the layers of the middle coat. From the examination of these pathological specimens, and from the fact that the attachment of the ex- ternal fibres of the middle coat to the cellular is much firmer than that of the layers of the middle coat between themselves, Dr. Pennock is induced to believe that dissecting aneurism, when it occurs to any extent, will be found to be between tht laminae of the middle coat, and not between the middle and the outer coats of the artery. An excellent paper by Mr. Peacock on this form of aneurism is contained in the Edinburgh Medical and Surgical Journal for Oct. 1843.)] The causes of perforation of the internal and middle coats, and the formation of false aneurism, are,—1. ulceration, generally occasioned by the detachment of calcareous incrustations, by athero- matous depositions under the internal membrane, and, more rarely, by tubercles, or small abscesses in the substance of the fibrous tunic : 2. rupture, or cracking, which takes place when the tunics have been deprived of their elasticity by cartila- ginous, steatomatous, fungous, and calcareous de- generation.* The immediate or exciting cause of the rupture is generally some violent exertion or accident; and in most instances patients with aneurism date it from some occurrence of this kind. Rupture does not appear ever to take place in a perfectly sound artery ; and if it did, the ex- periments of Dr. Jones prove that it would not be followed by an aneurism, as an effusion of lymph takes place, which strengthens the vessel in the lacerated part, (Jones on Hemorrhage, p. 125.) While aneurism of the ascending aorta and arch are, in the first instance, almost invariably true, though they occasionally become mixed, those of the descending aorta are generally false; and the caliber of the artery is, with few excep- tions, not in the slightest degree dilated opposite to the tumour. Aneurism by perforation of the internal and middle tunics is the only species of which Scarpa admits the reality ; but the inaccu- racy of his opinions has been fully proved, and, as before stated, there is no longer any question respecting the actual existence of aneurism by dilatation of all the coats. The cases of false aneu- rism that are on record are very numerous. Re- ference may be made to the works of Lancisi, Morgagni, Guattoni, Scarpa, Desault, Warner, Hodgson, Home, Laennec, Bertin, and Bouil- laud. 4. Mixed Aneurism, or false Aneurism surmounting true.—This species is formed in the following manner. All the three tunics of the artery first undergo an expansion, which, ac- cording to its form, constitutes either a dilatation or a true aneurism : as the expansion proceeds, the internal and middle tunics burst and the ex- ternal, being more extensible, dilates into a sac, surmounting the original enlargement. Aneurisms of this description are very numerous. Whether the cyst succeeding a perforation of the arterial walls has been preceded or not by their dilatation; in other words, whether the aneurism is true or mixed, it communicates with the cavity of the aorta by an aperture more contracted than its body, and circumscribed by a prominent border, correspond- ing with a kind of strangulation. This disposi- tion of parts has been perfectly described by Scar- pa, and admirably represented in his plates. General observations ox aneurisms o? THE AORTA. Haller and MM. Dubois and Dupuytren have remarked a variety of aneurism, in which the * Scarpa on Aneurism, §20,21, -22. Laennec de 1'Aus- cult. toin. ii. p. 704. Hodgson, p. 62. AORTA, (ANEURISM OF THE) 129 internal membrane makes a hernia through the ruptured fibrous coat and lines the sac, which is formed by the external or cellular coat Hernia of the internal membrane may occur, according to Laennec, in very small aneurisms : he had seen it in two, which were not larger than cherries; but when the tumour increases, the internal mem- brane speedily bursts. This he found to have been the case in two other aneurisms which did not exceed the size of walnuts, (De l'Auscult torn. ii. p. 693.) The experiments of Mr. Hunter, Scarpa, and Sir E. Home prove, that when the external and middle coats of an artery are remov- ed, the internal one does not dilate into an aneu- rism, but either bursts, or is strengthened by gra- nulations arising from its surface, and by adhesions formed with the surrounding parts. Corvisart having found several firm, solid tu- mours, of the size of nuts, intimately adherent to the aorta, while the external and middle coats ap- peared to be deficient at the point of attachment, was led to imagine that extraneous tumours, for such he conceived them to be, becoming adherent to arteries, led to the formation of aneurism, (Essai sur les Maladies du Cceur, p. 313.) Hodgson, on the contrary, regards the tumours in question as instances of aneurism cured, the sac having been filled up by lamellated coagula, (On Diseases of Arteries, p. 127,) and the volume of the tumour diminished by absorption; and Laennec, Bertin, and the best authorities subscribe to his opinion. As an aneurismal sac enlarges, the surrounding parts become involved in its composition. Thus the bones, muscles, and various other structures, often contribute to its formation. The viscera, also, become implicated when the tumour is situ- ated in their vicinity ; and the membranes with which they are invested being distended to their Utmost, finally yield, and the sac bursts into their cavities. Accordingly, aneurisms frequently prove fatal by discharging their contents into the lungs, oesophagus, stomach, intestines, bladder, &c. The size which the tumour attains depends upon the nature of the surrounding parts, and is very much determined by their extensibility — a property which is almost in direct proportion to the quan- tity of cellular tissue of which they are composed. Hence it is that, when the disease is situated at the root of the aorta, where the pericardium sup- plies the place of the more extensible cellular coat of the vessel, the sac bursts into the pericardium before it has attained any great magnitude. Hence, also, it is that, in the cranium, where the arteries are destitute of the cellular coat, and are ill su pport- ed by the pia mater and the soft pulpy substance of the brain, aneurism is extremely rare ; for such a lesion of the coats of the arteries as would else- where give rise to aneurism, is here attended with rupture and apoplectic effusion. It has been al- ready stated, however, that the arteries of the brain are not insusceptible of dilatation. One of the first circumstances that almost inva- variably follows the formation of true aneurism is, the deposition of the fibrine of the blood upon the internal surface of the sac. This deposition takes place in successive concentric layers, which have a different aspect according to the date of their formation. The most central consist simply of blood more or less firmly coagulated, and they are Vol. I___17 probably formed subsequent to death ; a little far- ther the coagulum is drier, paler, and evidently composed of a large proportion of fibrine : still farther are layers of pure, whitish, yellowish, or greyish fibrine; and, finally, in contact with the walls of the cyst, are layers of the same matter, but completely opaque, of a somewhat friable con- sistence, like dryish paste, and very closely re- sembling flesh which has been deprived of its colour by boiling. The most recent layers adhere to each other so slightly as almost to float within the sac; those beneath are united by a flossy or nappy cellular tissue, the adhesion being stronger in proportion as the layers are older. Patches of vivid red, formed by reticulated blood-vessels, are occasionally found in the fibrine, and blood often penetrates between its layers, and stains those which are friable, or decomposed. Coagula are softer in some cases than in others, though the physical circumstances be the same in both. The difference is probably owing to a difference in the chemical qualities of the blood. From these ana- tomical characters it is evident that lamellated coagula form by the successive depositions of the fibrine of the blood ; and the depositions are ac- counted for by the stagnation of the blood within the sac ; for it is proved, by experiment and ob- servation, that coagulation of this liquid takes place whenever its course is interrupted; hence the polypi that are found in the heart, the great veins, and the arteries, when the circulation through those parts is obstructed. The coagulation of blood within a false aneurism is favoured by two circumstances, the narrowness of the aperture of communication with the artery, and the rugged- ness of the interior of the sac. In true aneurism, as has already been stated, the width of the aper- ture of communication, and the smoothness of the interior of the sac are unfavourable to the coagulation, and accordingly fibrinous layers are very seldom found in those aneurisms, unless they are of great size, although they often contain co- agula in masses attached at one part only by a peduncle of greater or less thickness. The thick- ness of fibrinous depositions within aneurisms is sometimes very great Most commonly it is from half an inch to an inch and a half, but we have seen it exceed three inches : it is generally greater on one side of the sac than another. Laennec has seen fibrinous coagula as compact and dia- phanous as horn softened to the utmost by heat, and of a thickness exceeding five inches' breadth. Aneurisms, and the diseases of the coats of arteries which precede their formation, are much more frequent in men than in women. Of sixty- three cases seen by Hodgson, fifty-six occurred in the former, and only seven in the latter. (On Diseases of Arteries, p. 87.) We have found the proportion rather larger in females with respect to aneurism of the aorta, but with respect to ex- ternal aneurism it is much smaller, perhaps not exceeding one in fifteen to twenty. [In the winter of 1843-4, Dr. Dunglison had an opportunity of exhibiting to the clinical class of the Philadelphia Hospital the morbid appearances presented in three cases of internal aneurism :— two of the aorta, and one of the internal Macs— which occurred in the wards under his charge. The subjects were all females.] 130 Effects of aneurisms of the aorta os the contiguous parts. The effect of aneurisms of the aorta on the con- tiguous parts vary according to the volume, the form, and the position of the tumour. Dilatation, when not very considerable, produces little de- rangement of the surrounding parts ; for as the swelling is equable and diffuse, it does not exert a pressure on any one organ in particular, and its magnitude is not such as to create much inconve- nience from general infarction. The worst of its effects are those which it produces on the trachea and great bronchi; for though the pressure be slight, it often suffices, in consequence of the great irritability of these parts, to occasion considerable dyspnoea. It must not, however, be imagined that dilatation is an unimportant affection : it will hereafter be shown that, when complicated with enlargement of the heart, which it generally brings on, it is one of the most formidable diseases inci- dent to the circulatory apparatus. An aneurism which forms a defined tumour, whether it be of the true or the false species, and whether it be large or small, may produce the most pernicious effects. These are,— 1st. Such as result from compression of the neighbouring parts. 2d. Such as result from their destruction. 1st. By compression, the functions of the lungs, bronchi, heart, and oesophagus, are deranged, and that sometimes to a fatal extent. In the abdo- men the functional derangements are compara- tively inconsiderable, and very rarely endanger life. The reason of this is twofold,—first, that the abdominal organs are not of so vital a nature as the thoracic; and secondly, that the tumour, instead of being pent up in a rigid bony case like the chest, is permitted, by the yielding of the in- testines, and the distensibility of the abdominal parietes, to expand freely in almost every direc- tion. Pressure on any particular organ, therefore, is in a great measure obviated by the want of counter-pressure—of a fulcrum. Ventral aneurism, however, sometimes deranges the respiration by preventing the due descent of the diaphragm ; an effect which may proceed either from the magni- tude alone of the tumour, or, what is much more common, from its being seated near or in the sub- stance of the muscle, and impeding its motions. Ventral aneurism is also occasionally character- terized by involuntary evacuation of the urine and freces, by remarkable alternations of constipation and diarrhoea, and by deep-seated excruciating pains, resembling those of lumbar abscess. These symptoms arise from compression of the nerves, particularly the hypogastric plexus around the aorta. 2d. The consequences of destruction of conti- guous parts are far more formidable than those resulting from compression. When the tumour exerts an unusual pressure on any organ or tex- ture, adhesive inflammation takes place and unites the parts in contact. As the pressure increases, absorption and ultimately perforation of the sac ensue, and death from internal hemorrhage is the immediate consequence. The perforation takes place either by sloughing, or by laceration, ac- cording to the nature of the membrane or texture perforated. Thus, when the tumour advances to AORTA, (ANEURISM OF THE) ~~the skin, or when it extends into a cavity lined by a mucous membrane, it bursts by the separa- tion of a slough which has formed upon its most distended parts, and not by laceration. On the contrary, when the sac projects into a cavity lined by a serous membrane, sloughing of the mem- brane does not take place, but the parietes of the tumour, having become extremely thin in conse- quence of distension,'at length burst by a crack or fissure, through which the blood is discharged. An aneurism may burst into a great variety of parts, which we shall notice in succession. When the lungs are in contact with the tu- mour, adhesion, absorption of the sac, and rupture of the pleura take place, and the effused blood deluges the bronchi and causes suffocation. It often happens that an aneurism of the ascending aorta, or arch, compressing the trachea, or one of the great bronchial trunks, opens its way into it by ulceration of the cartilaginous rings and slough- ing of the mucous membrane, and causes suddenly fatal hemoptysis. More rarely, perforation takes place into the oesophagus, and death then ensues from haematemesis. Aneurisms occasionally burst at the origin of the aorta, and cause death by effusion of blood into the pericardium. The fatal event, however, is not always so sudden as" in the preceding cases ; a circumstance which Laennec attributes to the pericardium being supported, and the effusion, consequently, restrained, by the ge- neral infarction of the chest, occasioned by the presence of the tumour. This reason appears to us unsatisfactory, because, as before explained, aneurisms at the root of the aorta generally burst before they attain any considerable magnitude: nor, if large, would the resistance offered by the atmospheric pressure in the lungs, equal the force with which the blood tends to escape into the pericardium — a force equal to the propulsive power of the left ventricle. It is, perhaps, more probable that the inextensibility of the pericardium beyond a certain point, and the resistance of the heart to compression, form the principal powers which limit the effusion of blood. It would ap- pear that life is sometimes protracted for a consi- derable period after the rupture of the sac ; for in specimens presented to the Societe de la Faculte de Medecine by M. Marjolin, the margins of the aperture, according to Laennec, were polished, as if of old standing, and, as it were, fistulous.. (Laennec, Opt Cit. ii. p. 715.) Rupture into the pericardium is very rare. Laennec never met with an instance. The first that has fallen under our own observation occurred recently at St. George's Hospital. Morgagni (Epist xxvi. Nos. 7, 17, 21) and Scarpa, (On aneurism, § xix. p. 103, et sequent,) however, have collected together a considerable number of these cases, and Hodg- son saw two, in which the aneurism, beginning half an inch above the semilunar valves, occupied the whole ascending aorta and arch. Aneurisms have been known, but very rarely, to burst into the pulmonary artery. MM. Payen and Zeink saw an instance, (Bulletin de la Fa- culte de Medecine, 1819, No. 3,) and Dr. Wells another.* Professor Monro, tertius, showed us a preparation of an aneurismal pouch springing * Trans, of a Society for the Improvement of Med. Chirurg. Knowledge, vol. iii. p. 85. AORTA, (ANEURISM OF THE) 131 from the aorta, directly against the pulmonary artery ; and it is probable that, if the patient's life had been prolonged, rupture would have taken place into the artery. The left, cavity of the pleura and the posterior mediastinum are the parts into which thoracic aneurisms most frequently burst It is extremely seldom, on the contrary, that they open into the right pleura. Laennec has seen an aneurism of the descending aorta, which had compressed and destroyed the thoracic duct, and produced engorgement of all the lacteal ves- sels. Aneurisms sometimes compress the de- scending vena cava, and cause cerebral conges- tion, oedematous intumescence of the face, and even apoplexy. We have met with several in- stances of this kind. Corvisart,* and Bertin and Bouillaud, (Traite des Maladies du Cceur, p. 137,) each cite a case of apoplexy thus occasioned. Another effect of aneurisms is to obliterate ar- teries springing from or contiguous to them. We have met with two cases in which both the left carotid and subclavian were plugged up at their origin from the tumour. The obliteration is some- times effected, not by a plug of lymph, but by contortion or compression of the vessel. Mere contraction of the origin of arteries from these causes is very common. Ventral aneurisms may open their way into the various abdominal vis- cera, as the intestines, the bladder, &c. Aneurisms not only cause destruction of the soft parts, hut, what is still more remarkable, erosion of the bones. This phenomenon has been variously explained. The old pathologists erroneously ascribed it to a chemical solvent power of the blood. Hunter, Scarpa, and Hodgson, thought that it resulted from absorption of the earthy mat- ter, in consequence of the pressure of the sac. Corvisart and Laennec attribute it to a sort of de- trition or wearing down, produced by a purely mechanical action. Bertin and Bouillaud believe that it is more or less dependent on inflammation. To us it appears that absorption and mechanical detrition are the principal agents concerned in producing the effect. That pressure is capable of exciting absorption of bone is certain, as the ver- tebras have been found excavated by an aneurismal tumour, without being divested of their perioste- um (Hodgson, p. 79.) ; and there can scarcely be a doubt, that, when a denuded bone is exposed to the constant dashing of a column of blood, it un- dergoes disintegration by the mechanical detach- ment of its particles. Whether inflammation ever contributes to the effect, is difficult positively to determine. Appearances, however, are adverse to this opinion, as pus has never been found on bone eroded by an aneurism ; as exfoliation scarcely ever takes place ; and as nothing is discovered on it analogous to the cicatrization or irregular repro- duction which is observable in other bones when affected with caries. Cartilage, whether exposed to the action of the blood in aneurismal sacs, or to the pressure alone of the tumour, either remains entirely uninjured, or suffers incomparably less than bone. This is most manifest in the inter- vertebral substance, and the cartilages of the false ribs. The circumstance is attributable to the elasticity of cartilage, which protects it from me- * Journal de Medecine, par MM. Corvisart, Leroux, et Boyer, torn. xii. p. 159. chanical disintegration, and to its almost inorganic structure, which renders it little susceptible of ab- sorption or ulceration. The bones liable from their position to be eroded by aneurism, are the vertebrae, the sternum, the ribs, and sometimes the ossa ilii. It is principally by aneurisms of the descending aorta that the vertebra? are injured. In these cases the portion of the sac in contact with the vertebra is entirely destroyed, and its borders adhere very firmly around the eroded part of the bone, on which the blood plays freely in conse- quence of the fibrinous layers having been ab- sorbed at that part. The destruction is sometimes so deep that the shell of the vertebras forms the only partition between the sac and the spinal canal. Very rarely, however, does rupture take place into the canal. We are not aware that there are more than two instances on record, one by Laennec in the Revue Medicale for 1835, and another of which the preparation, by Mr. Chandler, is in the Hunterian Museum. Ventral aneurisms seldom produce erosion of the bones; because the abdominal viscera and walls yield to the tumour. It is by aneurisms of the ascending aorta that the sternum and ribs are eroded, and the tumour generally presents on the right side. Aneurisms of the arch and the innominata project at the upper part of the sternum, and about the clavicles, which they have been known to dislocate at their sternal extremities. When the tumour is con- nected with the posterior part of the arch, it shows itself underneath the left clavicle. According to Hodgson, when the periosteum contributes to the formation of the sac, its vessels continue to secrete an earthy matter, which, in some instances, has been deposited to such an extent as to form a considerable portion of the tumour. Small aneurisms have the effect of destroying the bones in a greater degree than large; a cir- cumstance attributable to the greater concentration of the pressure exercised by them. Signs and diagnosis of aneurisms of the aorta. The signs of aneurism of the aorta are of two classes. 1. General signs. 2. Signs afforded by auscultation, percussion, &c. These two classes of signs will first be described separately, and a brief summary then given of the signs of the two classes conjointly, which refer to the several forms of aneurism. I. General signs of aneurism of the aorta* When an aneurism is buried deep in the chest, and not capable of being detected by the sight and touch, it does not present a single general sign which is peculiar to itself, and, therefore, pathog- nomonic of its existence. There are even cases in which it occasions no functional derangement—no inconvenience whatever; and the first circum- stance that unveils the truth is, the sudden death of the patient while apparently in the enjoyment of perfect health. We have met with six or seven instances in which large aneurisms had existed without awakening even a suspicion in the mind of the medical attendant. One, in particular, 132 AORTA, (ANEURISM OF THE) eluded the penetration of a distinguished foreign auscultator, though he explored the lungs with eminent success. We are acquainted with only one general sign of aneurism of the thoracic aorta which is unequivocal and certain, namely, a tumour presenting externally, and offering an expansive as well as heaving pulsation, synchronous with the action of the heart. Of the remaining general signs, a large class are identical with those of organic disease of the heart, viz. palpitation, dys- pnoea, cough, tendency to syncope, terrific dreams, starting from sleep, haemoptysis, livid or otherwise discoloured complexion, cerebral or hepatic con- gestions, serous infiltration, &c. This identity arises from an identity of cause ; namely, an ob- stacle to the circulation, which depends either upon the aneurism alone, or conjointly upon it and a disease of the heart, to which, sooner or later, the aneurism almost invariably gives birth. It is obvious, therefore, that the signs of this class are equivocal. There are, however, certain other general signs which are more characteristic : yet even these are of themselves ambiguous and un- satisfactory ; as they only bespeak lesions of the viscera, or derangement of their functions, but do not proclaim the latent cause of the mischief. But when they coincide with the signs derived from auscultation, they lose their ambiguity, and rise into real importance; for the two classes of signs, general and stethoscopic, are a commentary on each other, and reciprocally borrow a precision and certainty of which they are individually desti- tute. We shall succinctly describe the general signs to which we refer, and subjoin to each the principal sources of fallacy. The means of detect- ing the latter we shall point out in the final summary. 1. When the tumour has attained a conside- rable magnitude, the cavity of the chest is preter- naturally crowded, and the patient complains of a sense of constriction, infarction, and oppression. But these sensations are common to almost all diseases of the chest. 2. The radial pulses are sometimes dissimilar, or one is extinct; an effect dependent .on obstruc- tion or obliteration of the arteria innominata, or left subclavian. But the difference of the two pulses at the wrist may proceed from a variety of causes independent of aneurism of the aorta, as, contraction of the origin of either subclavian from osseous, cartilaginous, steatomatous, or other depo- sition ; obstructions in the course of the artery, occasioned by tumours, wounds, subclavian aneu- rism, &c.; an irregular subdivision of the hume- ral, brachial, or radial artery. We have known the most ludicrous surmise.? occasioned by the radial crossing to the outside at the middle of the fore-arm, and the superficialis volaj supplying its place nt the wrist. 3. When the origin of either subclavian is con- tracted, the pulse at the corresponding wrist is a little later than the ventricular systole. We have not found this symptom uniformly present The heart is more frequently its source than the aorta, and we have observed it to be most considerable in cases of regurgitation into the left auricle ; but obstruction of the aortic valves may occasion it in a minor degree, particularly if this lesion is accom- panied with extenuation or atony of the ventricu- lar parietes. When the sign exists in both pulses, the presumption is strong that its source is in the heart 4. According to Corvisart, a purring tremor — the frimissement cataire of Laennec — is some- times perceptible to the hand at the middle or upper part of the sternum, and indicates aneurism of the ascending aorta. Purring tremor, above the clavicles, is an almost constant concomitant, and therefore a valuable sign, of dilatation of the arch ; but, according to our experience, it is unfrequently and imperfectly occasioned by sacculated aneu- risms, especially if lined by strata of lymph. We have never known the tremor to be occasioned below the clavicles by dilatation, unless the en- largement was so great as to extend beyond the lateral margins of the sternum, and allow the tremor to be felt through the intercostal spaces: but we have met with one case in which a dilata- tion of the pulmonary artery, though not volumi- nous, afforded a marked tremor between the carti- lages of the second and third ribs on the left side : this, however, is not remarkable, as the artery naturally lies nearly opposite to the part described. We have never known a sacculated aneurism create a tremor below the clavicles, unless the tumour had eroded the bones of the chest, and presented externally underneath the integuments. But the purring tremor may be occasioned in any part of the chest by mucous rattles, particu- larly those of the snoring kind, in the large bron- chial tubes; and we have observed that, when derived from this source, it is a very common cause of deception, in reference both to aneurisms of the aorta and ossifications of the heart. Purring tremor of the pulse is regarded as a sign, though it is a fallacious one, of ossification of the aortic valves. From many dissections, it has appeared to us to be generally connected with two .circum- stances, viz. a powerful action of the heart, and ruggedness, without appreciable obstruction, of the aortic orifice, or interior of the vessel. It therefore, seldom exists, unless either the action of the heart be accelerated, or the left ventricle be hypertrophous. 5. When the trachea, or primary bronchial divisions, are compressed by an aneurismal tumour, a harsh wheezing, or sibilous sound, proceeding deep from the throat, characterizes the respiration; the voice is either croaking or reduced to a whis- per, or it is a compound of both; the breathing is often extremely laborious, and when the heart is simultaneously diseased, dyspnoea sometimes oc- curs in paroxysms of the most suffocating severity. WThen the oesophagus is compressed, deglutition of solids is rendered difficult, and sometimes im- practicable ; for the descent of the morsel excites an excruciating pain from the summit of the sternum to the spine, or lancinating deeply in every direction through the chest. But compression of the trachea, or oesophagus, with the above symptoms, may be occasioned by tumours of any description. Wheezing respira- tion may proceed from an accumulation of gluti- nous mucus in the great branches. We have likewise known it produced in an extreme degree by laryngitis with thickening of the soft parts covering the arytenoid cartilages, and also by ossification and ulceration of the larynx from AORTA, (ANEURISM OF THE) 133 strumous, syphilitic, and mercurial disease. So difficult is it to distinguish the seat of wheezing respiration, that it has in many instances been imputed to an affection of the larynx, when it was in reality occasioned by an aneurism of the aorta; and bronchotomy has several times been actually performed with the view of obviating suffocation. 6. When the vertebrae are eroded, the patient suffers an intense terebrating pain in the spine; and when the brachial plexus of nerves is com- pressed by the tumour, an aching sensation per- vades the left shoulder, neck, scapula, and arm, with numbness, formication, and impaired motive power of the limb. But I have met with cases in which nearly similar pains were experienced, although there was no destruction of the verte- brae : and it is common to hear individuals affected with rheumatism or spinal diseases make the same complaints. The affection of the arm may be occasioned by various forms of organic disease of the heart, and it thus constitutes a part of that concatenation of symptoms which are denominated angina pectoris. We have likewise often met with it in hysterical females subject to palpitation, and occasionally in cases of pericarditis. In all these cases the pain probably originates in irritation of the cardiac plexus of the sympathetic, propagated to the brachial plexus. 7. When, in consequence of an adhesion be- tween the aneurismal sac and the pleura, the blood plays upon the lungs, a sense of ebullition is said to be experienced. But the same symptom is familiar to individuals labouring under phthisis, or chronic mucous catarrh ; and it proceeds from the successive bursting of large bubbles, formed by the transmission of air through the fluid in tuber- culous caverns, or in the greater bronchial ramifi- cations. 8. It occasionally happens that the patient suf- fers excruciating pain from a spasm, pursuing the course of the diaphragm, and binding the chest around, as with a cord. This symptom is too vague to be important, and it also occurs in hys- teria, gastrodynia, colic, spinal diseases, and rheu- matism of the diaphragm. 9. A pulsation is felt underneath the sternum, or ribs, at the superior part of the chest. This, although one of the least equivocal signs of aneu- rism, is not without ambiguity. It may be occa- sioned by a tumour of any description, as an en- larged gland, or a cancer, interposed between the sternum and the aorta, and receiving the pulsation of the latter. Even Dr. Baillie says, " But we are not to conclude from this symptom (viz., pul- sation at the superior part of the chest) that there is certainly an aneurism. I have felt the same kind of pulsation in other cases ; as, for instance, where the pericardium was found strongly to ad- here to the heart; where there was a slight in- flammation upon the surface of the heart, with a little more water than usual in the pericardium ; and where a morbid enlargement had taken place in the heart, without any aneurismal swelling." Every one much conversant with disease must have made the same observations. 10. A pulsation is felt above the sternum or clavicles. But this may be occasioned, 1st. by enlarged glands or other tumours seated on the K subclavian artery, and receiving its pulsation; 2d. by varix of the jugular vein at its junction with the subclavian ; both of which conditions have deceived expert practitioners; 3d. by subclavian aneurism. This affection sometimes resembles aneurism of the aorta so exactly, that it is ex- tremely difficult to distinguish them. Allan Burns records a case in which all the eminent surgeons of the district were unanimous in pronouncing the affection subclavian aneurism, yet it proved to be aortic. (Surg. Anat of Head and Neck, p. 30.) Sir Astley Cooper has published a number of simi- lar cases, and one is mentioned by Professor Monro tertius. (Elements of Anat. vol. ii. p. 249.) 4th. A pulsation above the sternum or clavicles may be occasioned by carotid aneurism. This, also, may readily be confounded with aneurism of the aorta, or of the subclavian artery. In April, 1826, we saw a case at Guy's Hospital, which led to much deliberation respecting the propriety of taking up the carotid above a pulsating tumour, supposed to be an aneurism of that artery. It was finally de- cided that the tumour was too low, and the design was judiciously abandoned. The affection proved to be a dilatation of the aorta and arteria innomi- nata. The carotid was sound. This state of parts was indicated to us by the stethoscope. Mr. Hodgson met with a similar case. (On the Dis- eases of Arteries, p. 90.) 11. The superior and middle parts of the chest are dull on percussion. But this sign is common to an infinity of other diseases, and the resonance is seldom impaired unless the aneurism be very large. It cannot be a subject of surprise that a series of symptoms liable to so many fallacies, should have proved insufficient, without the aid of auscul- tation, to dissipate the deep obscurity involving the diagnosis of aneurisms of the aorta. We have next to consider the second class of signs, namely, II. Signs of aortic aneurism afforded by auscultation, percussion, 27. 138 AORTA, (ANEURISM OF THE) by such means as have the greatest effect in en- feebling and retarding the circulation. Accord- ingly, the antiphlogistic treatment, rigorously pur- sued, is the most efficient remedy for aneurism of the aorta. This has acquired great celebrity un- der the designation of the treatment of Albertini and Valsalva. By detraction of blood and spare diet, they reduced their patients to so extreme a state of debility, that they were scarcely able to raise their arms from the bed. Morgagni reports (Epist xvii. art 30.) that when Valsalva had taken away as much blood as was requisite, he made it a custom to diminish the quantity of meat and drink more and more every day, till he pro- ceeded so far as to allow only half a pound of pudding in the morning, and in the evening half that quantity, and nothing else except water, and this also within a certain weight. After he had sufficiently reduced the patient by this method, so that, from weakness, he could scarcely raise his hand from the bed, in which he lay by Valsalva's order from the very beginning of the disease, he increased, by degrees, every day, the quantity of aliment until the necessary strength returned. To render this treatment safe and efficient, several circumstances must be taken into con- sideration. In persons of very feeble constitution, its employment is inadmissible, as it might be fatal by inducing other diseases, or irremediable de- bility. In individuals sufficiently strong to un- dergo the treatment, but in whom there is reason to apprehend that extreme debility, if long con- tinued, might occasion pernicious effects, this state, when once induced, should be speedily re- moved. The depleting system should be actively pursued in the first instance, so as to make a decidedly enfeebling impression on the circulation, and thus allow of the contraction of the sac and the deposition of a coagulum ; but when the pulse and general feelings of exhaustion indicate that the impression has been made, its protracted con- tinuance should be prevented by a spare, but nutritious diet, as a little strong beef-tea or mut- ton-broth. The quantity of blood to be drawn must depend upon the constitution of the patient and the effect produced. In one case under our care, gx. were abstracted for sixteen days conse- cutively, with an excellent result. Others we have seen bled to gx. or xii., twice a day, for six or seven days ; and this practice was pursued by Pelletan* and others ; but we have found the best effect to be produced with the least expendi- ture of blood by drawing a considerable quantity, as from gxv. to xxv., in the first instance, and repeating the bleeding to gx. or xv., within twelve hours, and then taking gvL or viii., every six or eight hours, or at such intervals as to prevent the establishment of re-action—a phenomenon, which, by producing an inordinate energy of the circula- tion, counteracts the effect of the depletion. Of this we can entertain no doubt, both from exten- sive observation on the human subject, and ex- periments on dogs; in the latter of which we have seen bleeding, repeated daily or every second day for ten days, occasion the most violent arterial throbbing.-J- In individuals who have not suf- * Clinique Chirurg. torn. i. Prera. Mem. sur les Aneu. itsmes, p. 54. t This subject has been developed with great ability, ficient constitutional vigour to give rise to much re-action, less frequent and more sparing detrac- tions of blood will suffice, as, for instance, from gvi. to xii., two, three, or four times a week. The blood after repeated abstractions becomes very serous, of a pale crimson instead of the natural dark venous colour, and has sometimes a whitish cream on its surface after standing twelve hours. In aneurism of the aorta, especially when con- joined with organic disease of the heart, the bleed* ing should never, if possible, be carried to syn- cope, as, in such cases, this phenomenon is apt to be alarmingly protracted, and sometimes to termi- nate fatally. The blood, therefore, should be drawn slowly, and in the recumbent posture. Nor should the venesection be performed during a paroxysm of palpitation, as the exhaustion conse- quent on it, superadded to that occasioned by the loss of blood, not unfrequently sinks the patient beyond the possibility of restoration. When there is much pain in the tumour, leeches afford great relief to it, while they, at the same time( conspire to reduce the circulation ; but they should not be applied when the integuments are very thin and discoloured, as they are apt to induce sloughing and rupture of the sac. Ice, as an ap- plication to the tumour, has been strongly recom- mended ; but the pain which it produces, is, in general, intolerable beyond a short time. Its occasional use, however, and, in the intervals, a cold cataplasm of linseed-meal and vinegar, are very serviceable, by contracting all the tissues and promoting the coagulation of the blood within the sac, when its current has been rendered languid by depletory measures. When cold applications are not employed, and the tumour is painful and requires support we have found the emplastrum belladonna afford the greatest relief. The diet should consist principally of fluids, and it should be gradually reduced. Pelletan some- times allowed only two basins of broth in twenty- four hours, and lemonade as a common drink. Valsalva, as before stated, gradually reduced the food to half a pound of pudding in the morning, and a quarter of a pound in the evening, with a limited quantity of water. By thus gradually reducing it both in quantity and quality, the solids may easily be brought as low as four ounces, and the fluids as eight, daily. In some even less is sufficient, and this for weeks together. Both the body and the mind should be kept in a state of the most perfect quietude. The recumbent posi- tion should be constantly maintained. Purgatives which have a great effect in weakening the action of the heart, should be frequently administered. Digitalis is useful by producing the same effect; but it should not be pushed so far as to bring the patient strongly under its influence, as the syncope induced by this drug is liable, in affections of the heart and aorta, to be fatal. We have several times seen it extremely alarming. The well-known effect of the superacetate of lead in controlling active hemorrhages, has intro- duced this as a remedy for aneurism. In Germany it has been extensively used for many years, and Dupuytren, Laennec,'and Bertin have employed fy, Dr: ,Marsha" H°H- in concert with whom we ner. formed the experiments alluded to. P APHONIA, 139 it with advantage in France. Our own experience is in its favour. Its tendency to produce colic, and inflammation of the mucous membrane of the stomach and intestines, may be counteracted by conjoining it with opium, and commencing with a small dose. Half a grain of each, gradually increased to a grain of the acetate in a pill, three or four times a-day, is the form in which we employ it. Any gastric irritation from it we have always found to be removed by a dose or two of castor-oil promptly administered, and mucilagi- nous diluents. When the patient has been re- duced as low as the constitution will bear, the state of the aneurism should be examined with the utmost attention. If it has undergone no amelio- ration, the treatment should be abandoned rather than the risk incurred of reducing the patient Further, and beyond the power of the constitution to sustain. But if it is clear that the pulsation and sound of the aneurism are greatly diminished or entirely suppressed, and the volume of the tumour reduced, the practitioner is justified in persevering,—so far as he can do it without bring- ing the life of the patient into palpable danger. When the amelioration has become confirmed, the treatment should be gradually relaxed, but absti- nence and the recumbent position should be en- forced, even for a considerable period after all the symptoms have disappeared. The treatment of Albertini and Valsalva should not be adopted in a rigorous manner, and with a curative view, unless the practitioner has reason to believe that the aneurism is of the false species, viz. by rupture of the arterial tunics ; or, if of the true species, that the sac is not a mere pouch, but so deep, and with so narrow a neck as to be con- siderably removed from the direct current of the circulation. The latter state may be presumed with some confidence when the tumour, supposing it to spring from the ascending aorta, extends far to either side ; or, whatever be its situation, when its base is remote from the caliber of the artery. Aneurisms of the descending aorta may be treated as false : post-mortem inspection having proved that they are almost always of that description. In cases of dilatation, and of shallow true aneurism, the antiphlogistic plan should be pursued to a moderate extent only, and merely with a palliative object: for as, under such circumstances, coagula scarcely ever form, a radical cure is not to be expected. It may be said, finally, that the efficacy of the treatment of Albertini and Valsalva has, in all probability, been somewhat over-rated. For, as the diagnosis of aneurisms of the aorta was in- volved in much obscurity until the last few years, it is certain that many cases, reported as cured, were not aneurisms, but tumours or nervous pul- sation simulating that disease. Another reason has prevented the treatment from maintaining its ground, namely, its severity. Though patients will submit to rest and extreme abstinence, they have rarely fortitude to see bloodletting superadded. The practitioner, on the other hand, has seldom the courage to insist upon it, knowing that it is not wholly exempt from danger, and that it will not infallibly be productive of a cure, especially if. not pursued with uncompromising rigour. Treatment of nervous pulsation of the aorta.—Though the treatment of nervous pulsa- tion does not strictly come under the head of aneu- rism, yet, as the pulsation is a frequent concomi- tant of aortic aneurtsms and organic diseases of the heart, it may not be foreign to our present purpose to advert briefly to its treatment. The indication is, to allay the nervous irrita- bility and excitement on which the pulsation de- pends. This may be effected by causing the pa- tient to maintain, as far as possible, a tranquil state of body and mind ; by a mild cooling diet and regular state of the bowels; by sedative reme- dies, as conium, hyoscyamus, camphor mixture ; and by these conjoined with antispasmodics, as assafcetida, valerian, sulphuric aether, if there be hysterical symptoms. It is scarcely necessary to add, that attention to the catamenial secretion is of primary importance. Wfren the patient is suf- ficiently tranquillized to bear tonics and stimulants, the best remedies are the various preparations of steel, with infusions and decoctions of cinchona, cascarilla, columba, orange-peel, &c, the shower- bath, much out-door exercise short of fatigue, and a nutritious but not heating diet. J. Hope. [AORTA, INFLAMMATION of the. See Au- TEHITIS.] APHONIA (from a privativum, and i>uvii, vox) is the term used by nosologists to designate that privation or suppression of voice, more or less complete, which occasionally takes place indepen- dently of coma or syncope. Dr. Cullen has ar- ranged it in the class Locales, and in the order Dyscineciae, (or impeded and depraved motions, from a fault of the organs ;) and has enumerated three species ; viz : 1. Aphonia gutturalis, from tumefaction of the fauces and glottis : 2. Aphonia trachealis, from tumours of neigh- bouring parts compressing the trachea: 3. Aphonia atonica, from mechanical division, or paralysis, of the nerves distributed to the tongue and larynx. In all these species the loss of voice is only symptomatic; and purely owing to the preterna- tural condition of the vocal organs. Indeed it is very doubtful whether aphonia is ever an idiopa- thic affection. In many cases of severe catarrh it is an attendant symptom, and depends upon the lining membrane of the larynx being slightly in- flamed and thickened; in the same manner as the Schneiderian membrane of the nose is thickened when we are incommoded by the sensation fami- liarly called " stuffing in the head." Again, in many instances aphonia precedes or succeeds apoplexy ; but in such cases it is indica- tive of plethora, or pressure, within the cranium, and is always to be regarded as a formidable symp- tom, not from the mere inconvenience of the loss of voice, which is only a subordinate matter, but from the proof it affords that the internal cause, whatever it be, that interrupts the nervous influ- ence, is situated about the base of the brain, and probably in the medulla oblongata, the part from which the nerves of the tongue originate. The medulla oblongata, where the crura of the cere. brum and cerebellum effect a junction with tite 140 spinal chord, seems to be the great centre of ner- vous union and sensorial power. Hence it has been accounted by pathologists the part of the nervous system most indispensable to life. Ac- cordingly, in those cases of apoplexy where the speech is much or permanently affected, our prog- nosis, for the reasons aforesaid, ought to be always unfavourable. Discussions of this kind, however, more properly belong to the head of apoplexy. We have sometimes met with aphonia depend- ing upon atony, or relaxation of the vocal chords, in consequence of long-continued over-exertion of the voice in speaking, shouting, singing, or the like. It is also now and then caused by ulceration of the lining membrane of the larnyx and its carti- lages ; a disease that gives rise to rapid emaciation, hectic fever, profuse expectoration of frothy mu- cus, and the other frightful symptoms known to modern practitioners under the name of phthisis laryngea. A fatal case of this sort, most distress- ing in all its details, lately came under our ob- servation, where the ulceration of the cartilages of the larynx occurred as the sequela of syphilis. For the most part, however, aphonia, where it occurs without any palpable disorder, or structural lesion, of the organs of speech, is a modification of hysteria; that Protean malady which assumes such various shapes and hues, and gives rise to such irregular, anomalous, and perplexing symp- toms ; resisting for months, or even years, the most assiduous and skilful efforts of the practi- tioner ! In cases of this class, the loss of voice is owing to irregular distribution of the nervous influence. This again is caused by general irrita- bility, or susceptibility, of the whole nervous sys- tem ; or, in other words, by " the hysterical tem- perament." We shall seek in vain to restore the voice until we have removed that hysterical dia- thesis on which the loss of it depends. Cure.—When the disease has not arisen from a cause which contra-indicated emetics, we have generally begun with one; and the following is what we have commonly employed, repeating it at intervals of three or four days, and adding to it, where the patient was robust, from gr. ss. to gr. i. of tartarised antimony: R Vini Ipecacuanhae f.^ix. Oxymellis Scillse f.^iii. M. The success that has attended its exhibition has been most conspicuous. Where the disease has appeared symptomatic of catarrh, we have followed up the emetic by saline, demulcent, and expectorant medicines. Leeches, but more especially blisters, to the fore part of the throat, have had an excellent effect. Where aphonia seems premonitory of apoplexy, the most prompt and effectual depletion by blood- letting, cupping, and purgatives, must be resorted to. Where, on the other hand, it is the conse- quence of apoplexy, we have chiefly relied on cupping inter scapulas, leeches to the temples, a blister to the head, and, above all, a 6eton in the nape of the neck. When aphonia is symptomatic of hysteria (as it so often is), the constitutional treatment adapted to the latter must be had recourse to. We would advise the following formulae, which we have APHONIA —APHTHA. poved by experience to be well adapted to this Ld many other varieties of hysterical disorder, R Ferri Subcarbonatis Qi. ad Jss. Valeriana, Pulveris gr. x. M. fiat pulvis ter die sumendus. Or the following pills and mature may be prescribed : R Pilulse Galbani Comp. Pyrethri pulveris, da ^i. Olei Anisi guttas vi. M. tere simul optime, et divide in pilulas xxiv. quarum sumat ii. vel iii. omni nocte. Necnon, R Sulphatis Ferri g. ii. Acidi Sulphuric. Dil. M. x. Solve, et adde Infusi Gentianse Comp. f.^ix. Aquae Cinnamomi f.sjiii. Sulphatis Magnesiae. 3L M. fiat haustus bis quotidie sumendus. With the above plan, the shower-bath every morning, at first tepid and then cold, (with or without the addition of salt to the water,) may be conjoined, and should be persevered in for several weeks. It is not unworthy of remark that, in one case of this disease, which had existed long, and re- sisted a great variety of remedies, we were fortu- nate enough to effect a cure by half-drachm doses of balsamum copaibx, given three times a day, rubbed up with mucilage of gum arabic and pep- permint or cinnamon water. A. Robertson. APHTHjE, (from the Greek oktw, accendo, to inflame,) is the term employed to denote those numerous white specks, or curd-like vesicles, that not unfrequently appear on the tongue and palate, and gradually diffuse themselves all over the inside of the mouth and fauces. They ought to be con- sidered inflammatory exudations rather than ul- cers; for they are not surrounded by any redness; and, when they alternately fall off and re-appear in successive crops, (as they are apt to do,) we find the cuticle abraded underneath, and the parts excessively tender and smarting, but the cutis vera unbroken. Three varieties are enumerated by Dr. Mason Good and other modern writers; viz. 1. aphtha infantum ,• 2. aphtha maligna; and, 3. aphtha chronica. Dr. Cullen has placed this disease in the class Pyrexiae, and order Exanthemata; but his collo- cation and definition apply more particularly to the aphthae infantum, or milk-thrush ,• which is the only variety that can be really or generally considered idiopathic. The others are purely symptomatic, and are chiefly of importance from their indicating a reduced state of the vis vitae, and an impoverished condition of the blood. We have witnessed the appearance of the symptomatic varieties in a great many acute dis- eases. In cases of enteritis ; in bilious, remittent typhoid, and petechial fevers ; in hectic fever, from confirmed pulmonary disease, or from the suppuration of psoas abscess in that irritable con- dition of the alimentary canal denoted by fever, vomiting and purging of bilious or other acrid matters; in the febris lenta attending diabetes, atrophy, &c.; in the fever accompanying slough- APHTHA, 141 ing wounds or scorbutic ulcers ; in short, in vari- ous states of great constitutional irritation and prostration we have found aphthae to supervene. They are always to be looked upon as a most un- favourable symptom ; not from any mischief in- herent in themselves, or caused by them, but from their indicating general exhaustion and prostration of the system. We have known, however, very many acute cases terminate favourably, notwithstanding the occurrence of aphthae during their progress; and, indeed, so long as the aphthous specks retain their purely-white colour, little danger need be appre- hended. But when the early crops fall off and are succeeded by others, at first yellow in their hue, and gradually degenerating into brown or black, they may be looked upon as almost infalli- ble tokens of a fatal issue to the concomitant dis- ease, whatever that disease may be. In such disastrous circumstances the aphthae pervade the whole alimentary canal. Indeed some authors of reputation contend, from the cardialgia, singultus, acid eructations, and gripings that usu- ally precede or accompany them, that they always originate in the stomach, even before they mani- fest themselves in the mouth and fauces. Be this as it may, it is unquestionable that in all cases where aphtha? show themselves, they are preceded by evident acrimony in the stomach and duode- num. The treatment, under such a state of things, ought obviously to be directed rather to the con- comitant disease than to the aphthous condition of the mouth and throat. But as the latter is often productive of great distress in swallowing either nourishment or medicine, gargles and other topical detergents must not be neglected. We have experienced beneficial effects, in some severe cases, from pencilling the inside of the mouth with a solution of argentum nitratum, in the pro- portion of gss, or even 9 ii, to an ounce of water. Gargles also of sage-tea, or of simple infusum ros», are often useful. One drachm of alum to a pint of infusion of red rose-leaves frequently has a good effect in cleansing the mouth. But, upon the whole, the most soothing application we have yet found is the following :— R Soda; boratis ^i. ad gii. Aquae f.^vii. Mellis rosae f.gvii. Tinct. Opii f.^i. M. fiat gargarisma. Frequent sips of this are to be taken, and held in the mouth for four or five minutes at a time, and afterwards discharged. The aphtha infantum usually attacks those children that are brought up by hand, rather than such as live entirely on the breast. In such cases the exciting cause is the food not being properly digested, but becoming acid and acrimonious in the first passages. The first step in the treatment is well to evacu- ate the primae viae by castor-oil, magnesia and rhubarb, or manna dissolved in warm milk. Our next measures must be to obtund acrimony, and excite perspiration. These purposes will be best accomplished by the warm bath, particularly where there is much febrile heat, or where the child is tetchy and restless ; and also by fef ss of mistura creta; with M. v. of vinum ipecacuanhae, given every four hours. We would recommend the following formulae : R Cretan preparatae Qii. Mucilaginis acaciae f.gss. Tere simul, et adde aquae f.^iss. Liquor, ammon. acetat. f.gvi. Spir. aether, nitric, f.^iss. Vini antimonii f.sjss. M. The dose a table-spoonful every four hours. With infants who cannot employ a gargle, a linctus, consisting of gi of borax (sub-borate of soda), rubbed up in one ounce of mel ros», and applied frequently to the mouth and fauces by means of a feather, or a camel-hair pencil, is often a useful succedaneum. Where the aphthae put on a dark or sloughing appearance, the sulphate of quinine dissolved in the infusion of roses, or the decoction of bark acidulated with muriatic or dilute sulphuric acid, must be resorted to in doses adapted to the age and other circumstances of the patient. Port- wine or brandy must also be exhibited. Gargles and the inhalation of the vapour of warm water and vinegar, must likewise be employed. Of all to- pical applications, however, the most powerfully antiseptic we are acquainted with is the following: R Liquoris sodae chlorinatre, tincturae myrrhae da f.^ss. Aquae f.jfvi. Aquae rosae f.^i. M. fiat gargarisma saepissime adhibendum. A. Robertson. [There appears to be a marked difference be- tween the pultaceous inflammation of the mouth, that constitutes Aphthae Infantum, and the folli- cular inflammation that constitutes Aphthx Adul- torum. The latter — aphthous stomatitis — is seated chiefly in the follicles of the mucous membrane of the mouth ; hence the name folli- cular stomatitis, given to it by some. When the membrane is inspected at an early period of the disease, it presents the appearance of simple stomatitis; and afterwards, small transparent, grey- ish or whitish vesicles are perceptible, and at the base of each vesicle there is a raised ring, which is resisting, and of a white colour. Subsequently the vesicle gives way at the top, and allows the fluid to escape from it; after which it becomes transformed into an ulcer, which spreads, and is bounded by a red circle,— the raised border that occupied or surrounded the base of the vesicle gradually disappearing. Cicatrization succeeds,— at times rapidly, but at others gradually,— whilst at others, again, it is exceedingly tardy, and the ulceration is very apt to recur after it has once healed. Cases very difficult of management are occasionally seen in nursing-women; and, what is singular, they would seem to occur more frequently in certain localities than in others, owing to causes that have not yet been appreciated. The stomati- tis of nurses is not, however, peculiar to this coun- try, as has been imagined by some. The treatment of the aphthae of the adult must be regulated greatly by the concomitant condition. In the first instance, mucilaginous, and, afterwards, gently astringent collutories may be prescribed ; and, where the ulcerations are not numerous, they may be treated with solid nitrate of silver, sulphate of copper, or tincture of iodine. If inflammatory symptoms accompany them, the constitutional 142 APOPLEXY, (CEREBRAL) phenomena must be met by appropriate remedies. Often the affection is manifestly adynamic, and requires the use of tonics, as the cold infusion of cinchona; and very obstinate cases require the thorough revulsion which travelling air and exer- cise are capable of effecting. With the same view, the various eutrophics may be needed which are prescribed in other cases of faulty nutritive action of the dermoid tissues. (Practice of Medicine, 2d edit p. 32 .- Philad. 1844.) Robley Dunglison.] APOPLEXY Cerebral__Apoplexy (from the Greek word airoitXrieou, to strike) has been defined, loss of sensation, voluntary motion, and intellect or thought; respiration, and the action of the heart and general vascular system, being continued. The disease has been so termed from the suddenness and violence of the attack in many instances; and, for the same reason, the patient is said to be attonitus (thunder-struck), or sideratus (planet-struck); as if the disease were of un- earthly origin. It is liable to be confounded with syncope or fainting, and with natural sleep; from both of which, for the purposes of practice, it requires to be distinguished. In syncope, respiration is sus- pended, the pulse is not to be felt at the wrist, the features shrink, and the surface of the body turns pale and cold. In apoplexy, the reverse of all these takes place. It is less easy to discriminate between apoplexy and natural sleep : the distinc- tion can only be made, indeed, by our being able to rouse the person from sleep, however profound, by a certain degree of irritation : this cannot be done, or but very imperfectly, in apoplexy. The suddenness and violence with which apoplexy often makes its attack ; the total loss of conscious- ness, of feeling, and of voluntary movement that attends it; and the not unfrequently fatal termi- nation of the disease, are circumstances well cal- culated to attract, as they have actually attracted, the attention of physicians from a very early pe- riod. We find it accordingly described by the Greek and Roman writers, and their successors of the Arabian school, with a minuteness and accu- racy that have hardly been exceeded in modern times. Little, however, is to be found regarding its intrinsic nature till within a comparatively late period; and even at present the pathology of the disease is far from being satisfactorily settled, if we may judge from the various and contradictory opinions that have been entertained on the subject. General description.—There is great diversity in the mode of attack of apoplexy, as well as in the greater or less severity of its symptoms. Sometimes the attack is nearly instantaneous and complete; the patient, previously in apparent health, falling down insensible, with an immediate abolition of all the sensorial functions. On other occasions the approach of the stroke is felt by the patient; he puts his hand to his head, or makes an alarming exclamation of something unusual felt in the head ; and then falls down insensible. In most cases, (and probably it would be found so in all, if sufficient attention were paid,) the attack is preceded, for a longer or shorter period, by pain in the head, or by more or less of disorder in the sensorial functions; such as tinnitus aurium, im- ' perfect vision, numbness or a sense of pricking in the extremities, giddiness, imperfect articulation, loss of memory, drowsiness, or nightmare. The degree in which the sensorial functions axe im- paired in apoplexy is also various. In the more severe cases, sensation, voluntary motion, and in- tellect, are all entirely abolished. In slighter affections, the patient retains some degree of con- sciousness, is sensible to impressions, and capable, to a certain extent, of voluntary movement. The pupils of the eyes are variously affected at differ- ent times. Although, in many cases, they are observed to be largely and equally dilated, and in- sensible to the impression of light, there are still more" in which they are in a contracted state, though often unequally in respect of each other. Sometimes they contract and dilate alternately with great quickness, without being influenced by the stimulus of light. Sometimes one side of the body lies motionless, without manifesting the least degree of feeling, even when strongly irritated; while convulsive movements, with perhaps some degree of feeling, are perceived on the opposite side. We are then enabled to predict that, in case of recovery from the apoplectic state, hemiplegia will be left behind. The disease consisting essen- tially, as will be shown hereafter, in a suspension, more or less perfect, of the sensorial or propel functions of the encephalon, other functions are not necessarily deranged ; nor when they are so, is it in any uniform way. Respiration, in violent cases of apoplexy, is commonly slow and labori- ous, the patient snoring loudly as in deep sleep. At other times the breathing is natural. The general circulation of the blood, as indicated by the pulse at the wrist, is equally various in apo- plexy. Sometimes the pulse is slow, full, and bounding; with flushing and fullness of the face, and heat of the extremities : at other times the pulse is small and weak, or perhaps irregular; while the face is pale, the features are shrunk, and the extremities cold. In extreme cases, such as are likely to prove almost immediately fatal, the pulse from the beginning is imperceptible, or nearly so; the heart appearing to be paralyzed, aa well as the voluntary muscles. In such cases death quickly ensues. The alimentary canal is also variously affected in apoplexy. In some cases, the power of swallowing is lost or impaired; and in such it is hazardous to administer any thing by the mouth, as being likely to induce suffocation, or at least to excite violent cough, which is not without danger to the patient In numerous in- stances apoplexy is ushered in by vomiting; the disease then is often referred to a disordered state of the stomach, as the primary cause ; but gener- ally without reason, the disorder of stomach being mostly secondary, and dependent upon the brain. The mistake is important, as leading to the em- ployment of emetics, the use of which is not un- attended with danger. The bowels are commonly torpid in apoplectic cases. Sometimes, however, the urine and faeces escape involuntarily. This marks a state of disease which generally proves fatal. Profuse sweating is also among the most unfavourable signs. Apoplexy may last but for a short time, as a few minutes, and then entirely disappear ; or it may prove fatal immediately, or after the lapse of a few APOPLEXY, (CEREBRAL) 143 hours ; it may even continue for several days, and then prove fatal. In a considerable number of instances it ends In hemiplegia, consciousness re- turning, while voluntary motion, and sometimes sensation, are lost. Palsy has thus been called a minor degree of apoplexy. Hemiplegia may take place in very different degrees : the entire half of the body sometimes suffers, the medial line being marked with great accuracy ; so that one half the tongue only, with its muscles, is paralyzed. Or the affection may be confined to the face, or to a single limb. The approach of apoplexy is some- times denoted by merely a loss of feeling in one or more of the fingers. In some cases of hemiplegia, the sensibility of the part remains, or is even morbidly increased ; while the voluntary muscles are alone paralyzed. In higher degrees of the disease, both the blood-ves- sels and the absorbents appear to partake of the paralysis, if we may judge from the weaker state of the pulse, as compared with that on the sound side, and also from the oedematous state of the limb; which seems to show deficient absorption. In all cases of apoplexy there is a disposition to a recurrence of the disease ; the number of fits and the period of recurrence being uncertain. In most cases the patient is sooner or later destroyed. Many persons survive a considerable number of slight attacks, but the more severe commonly prove fatal on the second or third occasion ; thus verifying, in some degree, the popular remark, that the third fit of apoplexy always kills the pa- tient Apoplexy may take place at any age, but is comparatively rare at the early periods of life ; and when it does occur in the young, it usually comes on slowly, and not by a sudden stroke, as at a more advanced age. A great. proportion of old people are cut off by apoplexy. The form of body appears to give a predisposition to the dis- ease, as a large head, short neck, and corpulency of habit. Luxurious diet, excess in drinking, pro- longed study, and intense thinking, are all circum- stances giving predisposition to the disease. Apo- plexy is of more frequent occurrence in men than in women ; probably from the former being more addicted to excesses, both as regards body and mind. Morbid appearances.—It is reasonable to ex- pect that the intrinsic nature of apoplexy might be determined by a careful examination, after death, of the organ principally affected. This, however, as will be presently seen, is true to a certain extent only ; for there are numerous in- stances on record of apoplexy proving fatal, where no change in the structure or condition of the brain could be detected, that was at all ade- quate to explain the symptoms of the disease, or to account for the death of the patient And even where manifest changes have been observed, they have been so various, and of so common a description, as to afford no complete or satisfactory elucidation of the subject. Many of the morbid appearances mentioned by writers as having been observed in the brain of persons who have died of apoplexy, are by no means to be considered as the immediate cause of the apoplectic state, since similar appearances are found in other kinds of cerebral disease, while they are not invariably met with in apoplexy itself. The morbid appearances to which we al- lude are, malformations of the cranium, ossifica- tion of the membranes or blood-vessels, adhesion of the membranes, false membranes, alteration in the texture of the brain, i. e. unusual hardness or softness, tumours, hydatids, concretions of various kinds, &c. On the other hand, cases of apo- plexy have been recorded in which the apoplectic seizure has proved fatal without leaving any dis- coverable lesion in the brain, though the symp- toms were well marked before death. To these cases, which are certainly uncommon, Dr. Aber- crombie has proposed to apply the term simple apoplexy. [It is also termed nervous apoplexy. The attack is almost always sudden, and immediately succeeding some powerful mental emotion. Should the symptoms of apoplexy have occurred many times; have continued for a short period only, and left behind them no 'evidence of modified con- dition of the encephalic neurine, it has been in- ferred that the apoplexy is of this variety. This inference might, however, be very erroneous, inasmuch as all the functional phenomena of apoplexy may be developed under a hyperamic condition of the vessels of the encephalon, which may soon pass away.] The morbid changes in the brain generally ob- served after death, which really appear to give rise to the apoplectic state, are the following :— 1. Extravasation of blood.—This is generally a fatal termination of apoplexy, and may be sus- pected, if not positively predicted, when the attack occurs suddenly and unexpectedly, the patient be- coming at once motionless and insensible, to which condition convulsions sometimes succeed. In other instances the individual does not become instantly insensible, but complains only of unea- siness or fixed pain in the head, often confined to one side. He may remain sensible for some time after the attack of head-ach; more or less oppres- sion, however, succeeds, till perfect coma is esta- blished, from which recovery never takes place. The blood in those cases is found extravasated most commonly in the substance of the brain in cavities of different sizes; sometimes there is a communication between the cavity thus formed and the ventricles, or the blood finding its way through a lacerated opening to the surface, becomes extravasated under the arachnoid membrane. When the blood has been effused in one hemi- sphere of the brain, palsy of the opposite side has been observed before death. The appearance of the extravasated blood varies according to the duration of the disease. When the apoplexy has proved suddenly fatal, the blood is dark-coloured, almost fluid, or in soft semi-liquid masses. If the patient survives for a longer period, the coagulum acquires a greater degree of consistency, and is of a pale red and sometimes dark yellow colour. The substance of the brain surrounding these apo- plectic cysts becomes altered ; it generally appears injected, and acquires a greater degree of softness ; this softened state does not extend deep, but be- comes gradually less and less perceptible, till it is impossible to discover any difference between the sound and diseased portion of the brain. The quantity of blood which is thus extravasated is 144 APOPLEXY, (CEREBRAL) very various : in some cases it does not exceed a few drops—often, however, two, four, or six ounces have been found in these cysts. Extravasation of blood, nevertheless, is not al- ways fatal, as appears from the changes observed in the brain of persons who have survived the apoplectic attack, but remained paralytic, with more or less disturbance in the sensorial powers. In such cases the blood which has become effused is partially or in some instances entirely absorbed, and the parietes of the cyst undergo a reparative process—a partial cicatrization ; they approximate and become slightly connected by soft intersecting bands, so as to form little cavities, which some- times contain a fluid of various quality and ap- pearance. The number of these old apoplectic cysts corresponds with the sanguineous effusions which have at different times taken place, and therefore several have been found in the same brain. In some rare instances these apoplectic cysts have been found completely cicatrized, which shows how much is often effected by the reparative powers of the system itself. With re- gard to the source of the hemorrhagic effusion, in apoplexy, it appears from the researches of M. Serres that the blood may in some cases proceed from the minute vessels of the brain without rup- ture, constituting that form of the disease to which the French writers have applied the term meningeal apoplexy : in these cases the blood es- capes from the vessels of the arachnoid into the subjacent delicate cellular tissue, or into the ca- vity of the ventricles ; and the substance of the brain is sound. When blood is found in the ven- tricles, it may proceed from this source, or from the vessels of the choroid plexus, or from a com- munication with an apoplectic cyst in the sub- stance of the brain. The hemorrhage, however, most usually takes place from rupture of the blood-vessels :* in el- derly persons the arteries of the brain often become diseased from ossification ; hence, when the blood is impelled with more than ordinary force, they are liable to give way, especially at those periods of life, when the solids in general lose their firm- ness.—« Omnes rami carotidis," says Haller, « qui cranio continentur, tenui, solida,, fragili magis, quam reliquae arteriae, substantia sunt."—Halleri prim. lin. % 337. Sometimes the blood issues from a congeries of these small arteries, occasion- ally from an artery of considerable size. Thus M. Serres traced in one instance the source of the hemorrhage to rupture of the communicating artery of Willis. In another individual it took place from aneurismal disease and rupture of the basilar artery. In one case, reported by M. Moulin, of apoplexy which proved suddenly fatal, six ounces of dark-coloured blood were found in the centre of the cerebellum, which had arisen from rupture of the trunk of the inferior cerebellar arteries. It would appear that, in all these cases, the morbid condition of the arteries constitutes the principal and primary lesion. In the sixth vo- * [This is not in accordance with the investiga- tions of pathologists. On the contrary, the appear- ances on dissection favour the view that the hemorrhage generally occurs from transudation through the parietes of the vessels, which in many cases are softened simul- taneously with or subsequent to the ramollissement of the encephalic neurine.j lume of the Edinburgh Medical Essays a case is given by Dr. Douglas, in which the left lateral sinus was ruptured ; and a very uncommon case (quoted by Abercrombie) is recorded in the Me- dical and Surgical Register of the Hospital of New York, of a man who was suddenly seized with hemiplegia of the right side, and died five days afterwards. On examination of the brain, blood was found between the dura mater and bone, which was traced to erosion of a vessel from caries of the inner surface of the parietal bone of the left side, not larger than a sixpence. The most frequent seat of extravasations of blood in apoplexy, according to Morgagni, is the corpus striatum. This opinion has been found substantially correct by modern writers. Of twenty-eight cases examined by Rochoux, in twenty-four the extravasation was found in the corpus striatum. [Of 386 cases, recorded by M. Andral, the extravasation was seated in the part of the cerebral hemispheres, situate on a level with the corpora striata and the optic thalami, and at the same time in both those bodies, in.............202 cases In the corpora striata, in.......... 61 " In the optic thalami, in........... 35 " In the portion of the hemispheres above the centrum ovale of Vieus- sens, in..................... 27 " In the lateral lobes of the cerebellum, in 16 « Anterior to the corpora striata, in... 10 " In the mesocephalon, in.......... 9 " In the spinal marrow, in.......... 8 " Behind the optic thalami, posterior lobes, in.................... 7 " In the median lobe of the cerebel- lum, in..................... 5 " In the peduncles of the brain, in .. . 3 " In one peduncle of the cerebellum, in 1 " In the corpora olivaria, in........ 1 " In the pituitary gland, in......... 1 " In the central white parts, in...... 0 " 386] Morgagni thought that the blood was more fre- quently effused on the right than on the left side of the brain. This, however, does not accord with the experience of Rochoux, who found, that of forty-one cases, examined after death, in eighteen the extravasation was in the left hemisphere ; in seventeen on the right side, and in six it had taken place in both hemispheres. 2. Serous effusion.—When serous fluid is ac- cumulated largely in the brain, so as to occasion apoplexy by pressure, the chief seat of the fluid is the different ventricles; though more or less is generally found every where between the mem- branes, often passing down the spinal column. Apoplexy may be suspected to depend upon this this cause, when the symptoms of oppressed brain come on slowly, and in an imperfect degree, without any thing like a sudden stroke or fit. In many of these cases, however, of what is termed serous apoplexy, a sudden and more violent attack succeeds, so as to prove quickly fatal; and in such cases blood as well as serum is often found effused in the brain after death. Hence it is ob- vious that no absolute line of distinction can be drawn between serous and sanguineous apoplexy > APOPLEXY, (CEREBRAL) 143 nor are they to be distinguished with certainty by symptoms during life. Serous apoplexy has been too generally sup- posed to be the only form of the disease to which persons of a spare infirm habit, with pale counte- nance and feeble pulse, are liable. This, how- ever, is a very erroneous idea. In many cases which have presented, during life, all the symp- toms and characters which have been usually re- garded as pathognomonic of serous apoplexy, ex- travasation of blood has been discovered on dis- section. Again, in fatal cases of apoplexy, in which serous effusion has constituted the only morbid appearance discovered, all the symptoms of sanguineous apoplexy have been observed during life, so that the only legitimate conclusion is, that the effusion is the effect of the previous vascular disturbance in the brain, and analogous to the dropsical effusion which often occurs after inflammation of serous membranes. It is equally apparent that the effusion is not the cause of the apoplectic symptoms,—these are produced by the morbid condition of the brain on which the effu- sion depends. The cerebellum being seldom affected in apo- plexy, (the disease being for the most part confin- ed to the cerebrum,) accounts sufficiently for the continuance of the action of the heart and of respiration during the fit; these functions being more immediately dependent upon this part of the nervous system. [This view is not sustained by the observations of modern physiologists. The action of the heart is certainly not more immedi- ately dependent upon the cerebellum ; whilst the medulla oblongata would seem to be the nervous centre of respiration.] For the same reason, other functions dependent upon the general circulation often go on unimpaired ; as secretions of various kinds, and the evolution of animal heat. In many cases an unusual degree of turges- cence of the veins upon the surface of the brain has been observed. This appearance has furnish- ed the grounds of the doctrine of venous conges- tion, of which so much use has been made of late, in attempts to explain the nature of apoplexy. But there is a fallacy here, which renders such an explanation very unsatisfactory, as will hereafter be shown. Causes of Apoplexy.—These have been di- vided into external or obvious, and internal, or such as can only be discovered by dissection after death. It is, however, necessary to observe that many cases are recorded of apoplexy taking place without any apparent external cause, while no internal cause, sufficient to account for the pro- duction of the disease, could be detected after death. The obvious external causes of apoplexy are the following : 1. Causes acting mechanically, by making pressure on the brain : such are, fracture of the skull with depression of a portion of bone; or blood extravasated immediately beneath the frac- tured bone, without depression. The reality of this cause is shown by the effect of direct pressure made upon the surface of the brain by the point of the finger, in cases where a portion of the skull has been removed by the trepan ; or on the fonta- nel le or opening between the cranial bones in the j Vol. I. —19 » head of infants. Some nations are said to destroy their supernumerary offspring in this manner. 2. Causes tending to increase the arterial action of the brain ; either by direct application to the head itself, or, indirectly, through the medium of other organs. Of the former kind are, insolation, or exposure of the naked head to the mid-day sun ; and erysipelas affecting the scalp. The in- direct causes of vascular excitement of the brain are various :—external heat applied extensively to the skin, either through the medium of the sur- rounding air, or by means of the hot bath ; breath- ing a heated atmosphere, especially in crowded rooms, the effect being probably increased by breathing contaminated air; the inhalation of car- bonic acid gas, and probably of other mephitic airs ; violent exercise ; certain emotions of mind, as anger, terror, or joy ; indulgence in the plea- sures of the table, intoxicating drinks, opium, and other drugs of the narcotic tribe. Violent con- cussion of the brain, occasioned by blows or falls, induces a suspension of the sensorial functions. or an apoplectic state. This suspension of func- tions may be momentary, or it may be more dura- ble ; even life itself may be instantly extinguished in this way, according to the violence of the shock sustained. 3. Causes which operate by impeding the re- turn of blood from the brain; as stooping; the application of a tight ligature round the neck, so as to compress the internal jugular veins; tu- mours of any kind so situated in the neck or chest, as to interrupt the return of blood from the brain to the heart; diseases of the heart or lungs imped- ing the transmission of the blood through the pul- monary vessels; or a voluntary suspension of breathing after a full inspiration; as in blowing wind-instruments, or in making great muscular efforts of any kind. The internal causes of apoplexy, or those that are only discoverable after death, are—extravasa- tion of blood in the substance of the brain or in the ventricles, or serous accumulations in any of the cavities, or between its membranes ; tumours of any kind, within the skull, of magnitude suffi- cient to press considerably upon the brain. Among the occasional causes of apoplexy also may be mentioned some forms of fever, and all the other forms of cerebral inflammation. Epilepsy and hysteria, likewise, often terminate their paroxysms by stupor, or an apoplectic state ; which in gene- ral disappears after a few hours, though it some- times ends fatally. Extreme cold, long continued, induces a state resembling apoplexy, as far as re- gards the suspension of the primary functions of the brain. How these different causes, at once so numer- ous and apparently dissimilar in nature, operate so as to produce the apoplectic state, is an inquiry of some difficulty. It is, however, one of much practical importance, as the rational, and probably the most successful treatment of the disease will depend greatly upon a knowledge of the particular cause, and its mode of acting. These will be more fully considered hereafter. Theory of Apoplexy.—There are two points here to be determined, or at least to be inquired into, namely, the primary and essential seat of the disease, and the intrinsic nature of the affection. 146 APOPLEXY, (CEREBRAL) With respect to the former, there is little difficulty. When we consider attentively the essential char- acters of apoplexy,—that they all refer themselves to the brain, and consist in a suspension or inter- ruption of the sensorial or proper functions of this organ, it would seem impossible to refer them to any other source. Some, however, have looked to the stomach as the primary seat of apoplexy, at least in those cases where the attack supervenes upon a full meal, or is ushered in by vomiting. The notion that a distended state of stomach acts by compressing the descending aorta, and thereby determining a larger flow of blood to the brain, is too mechanical to be probable. Were this a sat- isfactory explanation, it would be an easy matter to produce apoplexy at any time, by even mode- rate pressure at the pit of the stomach. An easier explanation may be given. The stimulus of a hearty meal, aided, as it commonly is, by strong drink and mental excitement, has been sometimes followed by, or it may be said, has given rise to, a fit of apoplexy ; but it is by exciting the vascu- lar action of the brain that such a cause operates. The brain is still the part from the affection of which the apoplectic state arises ; the stomach is merely the medium through which the brain is impressed. As to to the fact of many cases being ushered in by vomiting, thus affording, it was imagined, a proof that the stomach is primarily concerned, it is rather taking the effect for the cause. The same observation applies to the lungs. When the lungs are so diseased as to be unable to transmit the blood through them with sufficient freedom, the vital fluid will be deficient in those properties which it derives from the atmosphere in respiration, and by which it is fitted to maintain the living actions. In this state, it may, no doubt, contribute to the production of that general torpor of system which is so evident in such cases. But much more is attributable to the mechanical im- pediment afforded to the return of blood from the brain, by which the cerebral circulation is inter- rupted, and the functions of the organ thereby suspended or annihilated : apoplexy, therefore, is always and essentially a brain affection. The determination of the second point of the theory, viz., the actual condition of the organ affected—the brain—in other words, the proxi- mate or immediate cause of the symptoms, is a matter of greater difficulty, and about which a variety of opinions have been entertained; few of which, however, are deserving of serious no- tice. Among these may be mentioned the notion that the symptoms are caused by a morbid state of the animal spirits,—by fermentation or ebulli- tion of the blood,—by a relaxation of the nerves, —by spasm of the meninges or membranes cover- ing the brain,—or by spasm of the nerves and vessels of the brain, — (hence the term nervous apoplexy, still employed by some to designate those instances of the disease in which no morbid change is discoverable after death.) It is hardly necessary to observe that these notions are purely hypothetical, and rest upon no sort of foundation ; and much more cannot be said, it may be feared, in favour of the opinion of Dr. Cullen, that cer- tain of the causes of apoplexy operate by induc- ing an immobility of the nervous fluid. Other immediate causes of the apoplectic state have been assigned ; as compression of the cerebral sub- stance, and venous congestion ; both of which, however, are liable to insuperable objections, as will appear upon a fuller investigation hereafter. With much greater probability may the symptoms of apoplexy be referred to impeded or interrupted circulation in the brain, a state which most, if not all, of the known and obvious causes of the dis- ease have a manifest tendency to produce, and which seems fully adequate to the production of the effect, namely, a suspension of the sensorial functions. When it is added that the treatment of the disease will very materially turn upon the admission or disproval of this opinion, it will be readily allowed to be deserving of minute investi- gation. The nature of apoplexy in general, however, cannot be understood, nor its most essential symp- toms explained, nor the operation of its causes made intelligible, without adverting to certain physical peculiarities, by which the brain is dis- tinguished from other organs. These peculiarities are not now brought forward for the first time. They were long ago demonstrated by the eminent professor at Edinburgh, the late Dr. Monro, and have been recently confirmed by a variety of well- conducted experiments instituted on the subject by Kellie, Abercrombie, and others, who have drawn a number of important conclusions from the facts so established. These facts, as well as the inferences deducible from them, have been strangely neglected, and indeed have been scarcely at all referred to either theoretically or practically, by recent writers on diseases of the brain ; al- though it is quite impossible, without having re- course to them, to explain or even to comprehend a great number of the phenomena that attend such affections. The physical conditions, then, by which the brain is distinguished from other organs, are those which follow : 1st. The brain is enclosed in an unyielding case of bone, the cranium or skull, the contents of which are by this construction excluded from the influence of atmospheric pressure. 2dly. The cavity of the skull is always accu- rately filled by its contents, namely, the encepha- lon or general mass of brain, including the mem- branes, and vessels, and the blood contained with- in them. So long as the 6kull is perfect, there can be no rising and falling of the brain, so as in the latter case to leave a vacuity between the skull and the surface of the brain, these parts being al- ways in actual and close contact. 3dly. The contents of the skull solid as well as fluid, if not absolutely incompressible, at least are so by any force that can by possibility be' ap- plied to them during life ; and there is no air, or other elastic fluid, to be found within the cavity. This incompressibility of the cerebral substance is easily demonstrated by experiment. It is a property by no means belonging exclusively to the brain, more than to the whole of the animal solids. This is the less to be wondered at, when it is recollected how large the proportion of water is which enters into the composition of these, and that water, as well as other fluids, is so nearly incapable of compression as to require a vast force to render it at all perceptible. But although the APOPLEXY, (CEREBRAL) 147 substance of the brain, in common with other animal solids, be incompressible, its blood-vessels will readily yield to pressure, so as to be emptied of their contents; a necessary consequence of which is, a stoppage of the circulation in the part so affected. The pressure may be made to take place on any part of the brain, even the most remote from the principal vessels; yet nevertheless the pressure, by operating through an incompressible substance, may influence vessels the most distant, so as thereby to impede, if not wholly interrupt, the cerebral circulation. The circumstances above stated with respect to the brain, lead to very important deductions, both theoretical and practical. It follows, ex necessitate rei, that no material variation can take place, within a short period, in regard to the absolute quantity of blood in the brain. No additional quantity can be admitted into the blood-vessels situated there, the cavity of the skull being already completely filled by its contents. A plethoric state of over-fulness of the cerebral vessels altoge- ther, though often talked of, can have no real existence ; nor on the other hand can the quan- tity of blood within the vessels of the brain be diminished, any more than can wine or other fluid be drawn from a cask without furnishing an equivalent for the portion abstracted from it, by the supply of an equal bulk of air, which in the case of the brain can of course find no entrance. No abstraction of blood therefore, whether it be from the arm or other part of the general system, or from the jugular veins, (and still less from the temporal arteries,) can have any effect on the blood-vessels of the brain, so as to lessen the absolute quantity of blood contained within them. From the experiments of Dr. Kellie, it was found that in animals bled to death the brain still contained the usual quantity of blood; and in some cases the superficial veins were found gorged with blood, and the sinuses full; the rest of the body being at the same time blanched, and drained of its blood. In a few instances, the brain appeared to contain less blood than usual; but then there was found some serous exudation. When the cranium of the animals subjected to these experi- ments was perforated before they were bled, the brain was as much emptied of its blood as the rest of the body. In two instances of persons that had been hanged, the cellular membrane of the whole head externally was turgid with blood; but nothing peculiar was observed in the state of the vessels of the brain itself. When blood is sud- denly or rapidly extravasated anywhere within the skull, the space thus occupied can only be fur- nished by the compression and consequent empty- ing of the blood-vessels in other parts of the brain ; and in the same degree that this happens, it is evident that the circulation of such parts must be interrupted. But in the formation of tumours within the skull, and during the slow accumula- tion of serum from inflammation or any other cause, the cerebral substance itself may be absorbed, to an extent corresponding with the bulk of the tumour, or the quantity of serum deposited. The circulation of the brain may then go on uninter- ruptedly, and thus the apoplectic symptoms be prevented. But although, under ordinary circumstances, the absolute quantity of blood contained within the vessels of the brain must remain the same, there may be great differences in regard to its distribu- tion, and the force and velocity with which it is moved. Thus, the arteries of the brain altogether may be unusually distended with blood; but in this case the veins will be in the same degree compressed and emptied, and the circulation of the organ proportionally interrupted, with a corre- sponding interruption of functions. Again, there may be a partial fulness or disten- sion of vessels in one part of the brain only, but this must be at the expense of the rest of the brain, which will be proportionally deprived of the usual supply of blood. This will be the case in circumscribed cerebral inflammation, as well as in other cases of partial excitement of the organ. The different parts of the brain will then be in different, and perhaps opposite states, in regard to the performance of their functions. The functions of one of the cerebral organs may be excited, while those of another may be imperfectly carried on or depressed. Such an inequality in the state of the cerebral functions is observable in most diseases of the brain ; for there are probably few in which the whole organ is simultaneously and equally affected. In like manner there may be great diversity with respect to the force and velocity of circula- tion in the brain ; the absolute quantity of blood in the vessels remaining still the same. In this way the functions may be more or less excited, or more or less disturbed. These changes in the state of the cerebral circulation are all independent of the heart, the action of which has but little influence over the brain or its functions. It fol- lows, from what has been now stated, that blood- letting, when employed as a remedy in apoplexy or other brain-affections, however useful it may be and undoubtedly is, in many cases, does not effect its purpose by diminishing in any degree the absolute quantity of blood in the brain, but by reducing the velocity and impetus of the circula- tion there, and which it does by influencing the general system. We have seen that the changes observed in the brain of apoplectic persons are very dissimilar; and that, in some instances, as has been stated above, no material deviation from the natural state of parts has been found; it is plain, therefore, that such changes, when they do occur, cannot be the proximate cause, the causa continens, of the symptoms, but are to be considered, at most, as remote causes ; and, with regard to some of them, are to be looked upon rather as mere coincidences than causes. The opinion that appears to prevail most gene- rally at present, as to the immediate cause of the suspension of functions that constitutes the apo- plectic state, is that the remote causes of the dis- ease, such as extravasated blood, and accumulation of serum, produce a compression of the cerebral substance, thereby interrupting its functions. But, besides that some of the remote causes of apoplexy have no apparent tendency to make any direct pressure on the brain, it must not be overlooked that the cerebral substance being in its nature incompressible, cannot, so long as the blood is contained within its vessels, be exposed to greater 148 APOPLEXY, (CEREBRAL) pressure at one time than another. It must be in 6ome other way, therefore, than by compression of the substance of the brain, that the remote causes act in producing their effect. It cannot be questioned that pressure on the brain of any kind, if carried to a certain extent, is capable of inter- rupting the functions of the organ so as to induce apoplexy ; but there is good reason to believe that the pressure operates upon the blood-vessels, so as to impede mechanically the passage of the blood through them ;—in a word, that interrupted circu- lation in the brain is the proximate or immediate cause of that temporary suspension of the senso- rial functions which constitutes the apoplectic stale. To establish this opinion, it will be neces- sary to show ground for believing, first, that these functions are dependent, for their performance, upon the continuance of the cerebral circulation ; and, next, that all the remote causes, the operation of which is at all understood, have a manifest tendency to produce such an interrupted state of circulation in the brain. If these points ace estab- lished, it is plain that a different indication of cure ought to be followed, from that usually pur- sued. It can scarcely be doubted, we imagine, that the brain, in common with other organs, depends mainly for the performance of its functions upon the continued circulation of blood through its vessels, and without which those functions must soon cease to be performed. This dependence of the sensorial functions upon the circulation of the brain, is shown, first, in the case of syncope ; in which the action of the heart ceases altogether, or nearly so, for a time ; and, consequently, little or no blood is sent to the brain. In this case, the sensorial functions are suspended, the patient becoming unconscious, insensible to impressions, and without voluntary movement If, on the other hand, the return of blood from the brain to the heart be obstructed by causes influencing the veins, the same interruption is given to the circu- lation of the brain, and the same suspension of its functions follows. This is seen, where the head is made the most depending part, as in stooping, in persons who are predisposed to apoplexy : the vessels for a time are incapable of carrying the blood upwards against gravity, and it necessarily therefore stagnates in the vessels of the brain ; with the same consequence as before, suspension of the sensorial functions. Were it practicable to tie the internal jugular veins, it can hardly be doubted that the same effects would follow ; for a less complete obstruction to the return of blood from the brain, by these veins, produces similar effects; such, for example, as is occasioned by tumours in the neck, or in the course of the supe- rior cava, or by disease of the heart or lungs; all of which give a tendency to apoplexy. There is so far an analogy between the two states of syn- cope and apoplexy, that in both the circulation of the brain is interrupted, and in both the senso- rial functions are suspended. The difference is not as regards the brain itself, but the rest of the body. In the one case, (syncope,) the blood ceases to be sent to the head altogether; but in the other case, (apoplexy,) the bbod is stagnant in the brain only; while the heart continues its action, and the general circulation is still carried on, the pulse beats, and the vivid hue of the coun- tenance is preserved. ___ These two cases, of syncope and apoplexy, would seem to prove sufficiently that unless the circulation of blood through the brain be continued, the orean is incapable of carrying on its functions. But while this is admitted, it is of importance also to know that the brain is much less dependent upon the action of the heart and general vascular system than is commonly supposed. It is upon the action of its own vessels that the brain chiefly depends for the performance of its functions, and the modifications which those functions occasion- ally undergo, both in health and in disease. We frequently observe the action of the heart and general vascular system greatly increased and disordered, as in acute rheumatism and other active inflammations, where the pulse is full and strong, and the general circulation carried on with the greatest vehemence, and yet the proper functions of the brain are undisturbed. This it is not diffi- cult to understand, when we advert to the con- trivances of nature to guard the brain against any violent impulse of the blood, as derived from the heart; by the bony and tortuous canals through which the arteries enter the skull, the anastomo- ses which take place within, and the minute divisions and ramifications which the arteries sub- sequently undergo, before they arrive at, and are distributed throughout the cerebral substance. In other cases, where the blood is sent sparingly to the brain, and with the feeblest impulse,— where, in fact, the pulse at the wrist is scarcely perceptible, and the general circulation is nearly at a stand,—the brain nevertheless, preserving the action of its own vessels, and thereby maintaining its circulation, is found capable of performing some of its most important functions; and that often within a few moments of the termination of life. In fact, in all the diseases of the encephalon, it is the state of action in the cerebral vessels them- selves, and hardly at all that of the general vascu- lar system, which regulates and determines the phenomena and effects of the disease. The ex- pression therefore, determination of blood to the head, in such general use, appears to be unfounded, as implying that the quantity of blood impelled to the brain, and the force of circulation there, depend in any material degree upon the heart's action, instead of the action of the cerebral vessels them- selves. Of the mode of action of the remote causes of apoplexy.—Let us now proceed to inquire how far the different remote causes of apoplexy have actually a tendency to produce the effect supposed —that of interrupting the circulation in the brain, and thereby impeding, or more or less perfectly interrupting, its functions. The simplest remote or occasional cause of the apoplectic state is strong pressure made on the surface of the brain from without When, for example, the skull is perforated, or otherwise ren- dered imperfect, and the point of the finger is pressed with a certain degree of force on the brain, the animal becomes motionless and insensible—in other words, apoplectic; and this continues till the pressure of the finger is removed. According to the theory proposed, it is obvious that such pressure must of necessity have the effect of ob- APOPLEXY, (CEREBRAL) 149 structing, more or less, the circulation of blood through the organ. From the incompressible na- ture of the cerebral substance, such pressure may affect the vessels situated in the remotest parts of the brain, as readily as those to which the pressure is more immediately applied. Here, therefore, as far as the circulation of the blood in a part is necessary to the performance of its functions, we have an adequate cause of the suspension of functions which characterises apoplexy. In like manner, fracture of the skull, with depression of a portion of bone, or blood extravasated beneath it, equally induces an apoplectic state, by com- pressing the blood-vessels, and which is seldom relieved till the depressed portion of bone is elevated, and the extravasated blood removed. Extravasation of blood, or serous accumulation in the interior of the brain, must necessarily have the same effect, by taking up space which can only be furnished by the blood-vessels yielding to the pressure thus made upon them. In all these cases it is evident that the circulation of blood through the brain must be impeded or interrupted, in different degrees, according to the extent of the pressure so applied. If this should be great, and suddenly induced, such a degree of stagnation may take place, as to be incompatible with life itself. Again, if a tumour is formed within the skull, whether it be a morbid production of any kind, or a case of common inflammation ending in abscess, in either case space is required, which can only be supplied, either by the removal of a corresponding portion of cerebral substance by the slow process of absorption, or by the emptying of the blood- vessels of the brain, as the natural consequence of the pressure which such tumour is making on the surrounding parts. In all the cases above described, simple observa- tion, or dissection, will illustrate the nature of the disease, by pointing out the immediate cause of the impeded or interrupted circulation in the brain. But there are other cases of apoplexy, in which dissection detects nothing adequate to explain the symptoms; which, therefore, must be otherwise accounted for. It has been a very generally received opinion that such an increased determination of blood to the brain may take place as to give rise to an overloaded state of its vessels, so as to disable it for the performance of its functions, or, in other words, to induce an apoplectic state. This supposed determination of blood to the brain, and the impeded state of functions arising out of it, have been ascribed to increased action of the heart. But it has been already shown, that the brain is incapable of receiving any addi- tional quantity of blood in its vessels; conse- quently, there can be no such over-fulness as has been supposed, to account for the oppressed state bf the organ. And were it otherwise, the heart has no power of sending blood to the brain in greater quantity than to other parts. If the force of circulation in the brain be increased, as it un- doubtedly may be, such an effect is owing to the increased action of its own vessels, and not to that of the heart. The phrase, determination of blood to the brain, is, therefore, without meaning. i Much has been said of late of venous conges- M* tion, as one of the immediate causes of the apo- plectic state. This notion is founded, as before observed, solely upon the fact, that in some cases of apoplexy, the superficial veins on the surface of the brain are found gorged with blood. Hence it has been imagined that the same state of veins existed during life. It is, however, a great error to suppose that the appearances observed in the body after death are a true representation of what existed during life, especially as regards the blood- vessels. It is a general principle in physiology that the arteries, in consequence of the greater degree of contractile power naturally possessed by them, empty themselves into the veins, as their last act of life ; and accordingly the blood is prin- cipally found in the veins upon dissection. This law applies to the brain no less than to other parts; and consequently the veins, which are principally situated on the surface of the brain, running be- tween the convolutions, are always found more or less distended with dark or venous blood ; while the principal arteries, situated towards the basis, are found comparatively empty. Now no one can believe that this state of the arteries and veins of the brain, relatively to each other, could exist— that the arteries could be empty and the veins full, during life ; for such a state of things would be clearly incompatible with the regular movement of the blood, which requires that there should be a continuous stream throughout the vascular sys- tem. The blood which the veins contain, what- ever be its quantity, must be derived from the arte- ries ; and if there be found, after death, a more than usual quantity of blood in the veins,—if they are in a congested state, (to use a modern though unphilosophical expression,) or unusually gorged with blood,—it is only a proof that the arteries, at the time of death, had sent into them an extraordinary quantity of blood; and that they had probably been unusually distended during life. This is confirmed by the fact that such a gorged state of the veins on the surface of the brain is met with in those cases of disease in which the arterial action of the organ during life has been the most violent. The term congestion, therefore, as implying an unusually distended state of vessels in the brain, applies to the arteries, and not to the veins ; the gorged state of the latter taking place only at the time of death. The importance of this distinction will be seen, in laying down the treatment of apo- plexy, as well as other acute cerebral diseases. It remains to be shown, how such a distended state of the arterial system of the brain is calcu- lated to produce the apoplectic state, by impeding the circulation through the organ. This will be best illustrated by showing how the state called intoxication, or drunkenness, is produced by alco- hol, or other inebriating liquors. Alcohol, in all its combinations, and however applied to the body, proves a stimulus to the arteries of the brain; and in whatever way it produces its peculiar or specific effects, its action may be justly termed specific with respect to this organ, as it produces nothing similar, at least in an equal degree, on any other. This specific and stimulant power of alcohol with regard to the brain, is evinced by unequivocal proofs of increased arterial action in the whole head ; as well as by the disturbance in the state 150 APOPLEXY, (CEREBRAL) of the sensorial functions which it occasions. The increase of action in the external carotid arteries is manifested by the stronger pulsation and increased size of both the cervical and tempo- ral arteries, and by the flushing of the face, and redness of the eyes; all of which clearly show increased action in the branches of the external carotid : and that a similar state of excitement takes place in the internal arteries of the head and their ramifications throughout the brain, may be inferred with great probability from the increased heat of the whole head, and from the feelings of the individual, especially when recovering from the effects of intoxication ; at which time there is frequently violent throbbing head-ach. Admitting, then, that the peculiar and specific effect of alcohol is to stimulate and excite the blood-vessels of the brain to greater action, it will not be difficult to account for the different and even opposite effects of the same stimulus, accord- ing to the degree in which it is applied, and the time that has elapsed from its administration ; and certainly nothing can well be more different than the effects produced by a moderate use of wine, or other strong drinks, and the highest state of drunkenness. In the one case, the greatest energy and activity are displayed throughout the system —in the other, some of the most important func- tions of the brain are nearly annihilated. This apparent incongruity of symptoms, however, will vanish, if we advert to the effects of stimulation on arteries in general, as applied in different de- grees ; and, at the same time, recal to our recol- lection the peculiar physical circumstances in which the brain is placed, as already noticed. A moderate degree only of excitement of arte- ries merely increases their action, and augments, in consequence, the impetus and velocity of the blood through them, but without manifestly, or at least considerably, increasing their diameters. Under a more powerful degree of excitement, their diameters become enlarged ; the quantity of blood in them is increased, and at the same time put into more rapid motion. These effects may be readily seen upon immersing an extremity, the arm for example, in hot water : both arteries and veins become enlarged ; the blood circulates with greater force and velocity; and the bulk of the whole limb is increased. The same law doubtless holds good with respect to the blood-vessels of the brain. There is the same tendency as in other parts to enlarge their dimensions from the application of stimuli; but with this difference, that from the peculiar circum- stances in which this organ is placed, as before pointed out, there is not room for the simultaneous expansion of both arteries and veins. The arte- ries becoming enlarged in their diameters, as a consequence of their increase of action, occupy greater space within the skull than before, and in so doing necessarily compress the veins, these lat- ter being the only parts that yield to pressure. It is obvious, then, that the movement of the blood through the brain must be impeded, in proportion as the veins are suffering compression ; and this again will depend upon the degree of excitement and distension that exists in the arteries: and thus the different degrees and successive stages of intoxication are easily understood : in the first degree of excitement, by a moderate use of vinous liquors, the movement of the blood through the vessels of the brain is augmented ; the action of the arteries being simply increased, without any material increase of their dimensions, the veins are still in a condition to receive and to transmit the arterial blood. In this state of the circulation of the brain, the sensorial functions are simply excited, but without disorder; the powers both of body and mind are displayed with greater energy; but in a higher state of excitement from the same cause, the arteries of the brain become distended, the veins are pressed upon, and the circulation is proportionally impeded. Disorder of functions then succeeds to the previous state of simple ex- citement ; and if the stimulus be carried to the highest excess, the circulation of the brain becomes almost wholly interrupted ; and the consequence soon is an entire abolition of all the sensorial functions, or in other words, the highest degree of intoxication. This state continues till the excited and distended arteries gradually subside into their former and natural state of action and fulness; when the pressure is taken off from the veins, and the circulation through the organ is renewed: with this, a restitution of its functions takes place, the stupor gradually disappearing. Another cause of excitement of the arterial action of the brain is the hot-bath ; and, still more, the direct application of heat to the naked head, as in the coup-de-soleil, to which we have before adverted, both of which occasionally give rise to apoplexy; which however is generally temporary in duration, and for the most part with- out danger ; unless, from the violence of action, a rupture of vessels should take place, or inflam- mation should follow, when the character of the disease becomes changed. The apoplectic stupor that attends both of these cases, whether produced by the hot-bath or by insolation, admits of a ready explanation upon the principle of arterial fulness, as before illustrated. Again, the arterial action of the brain is strong- ly excited by certain emotions of mind, particu- larly anger and joy ; both of which, when exces- sive, have been found to induce apoplexy, and sometimes with a fatal result They may easily be conceived to operate in the way mentioned; namely, by arterial fulness producing venous com- pression, and consequently interrupted circulation in the brain. Lastly, inflammation of the brain, when gen- eral or extensive, whether it be a primary affection or arising in the course of other diseases, not un- frequently terminates in apoplectic stupor. At the commencement, just as in the early stage of intoxication, there is excitement, with more or less of disorder, in the sensorial functions : as the inflammation increases, the disorder of functions increases likewise ; there is then frequently furi- ous delirium. At length, stupor takes place, and the patient often dies apoplectic. Of all these changes we have frequent examples, in the cases of hydrocephalus, phrenitis, and idiopathic fever; these differ from ordinary cases of apoplexy, in possessing the characters of inflammation along with those of oppressed brain. In all, the same cause of cerebral oppression exists ; namely, ob- structed circulation induced immediately by arterial APOPLEXY, (CEREBRAL) 151 fulness ; which, in a circumscribed space, as that of the skull, must of necessity compress the only yielding parts, the veins, and thereby impede, and in extreme cases put an entire stop to, the circu- lation of the brain, and thus destroy life. Thus it appears that apoplexy may be produced by a variety of remote causes, all operating in different ways, but all leading to the same gen- eral result — obstructed circulation of the brain. Whether this be produced by direct external pres- sure, or by extravasated fluids, or tumours, within the skull; whether by arterial excitement and consequent distension, as produced by either alcohol, external heat, or mental emotions; — or whether by any impediment to the return of blood from the brain, by causes influencing the veins; — the effect is still the same, and suggests the same general indication of cure; namely, to re- store the circulation of the brain. The means, however, of doing this will vary according to the nature of the obstructing cause, the removal of which is the principal object of practice. It may be asked here, is there any cause (not mechanical) capable of influencing the sangui- ferous system of the brain exclusively, so as to paralyse, as it were, its blood-vessels, and thereby put a stop to the movement of the blood in that organ ? Is apoplexy ever induced in this manner ? Has carbonic acid, or any of the narcotic tribe, such a power ? Is natural sleep, in which the sensorial functions are all suspended, the result of diminished action in the blood-vessels of the brain, and consequent retarded movement of the blood through the organ ? And may not dream- ing and somnambulism be explained on the sup- position that some parts of the vascular system of the brain continue in an active state, while the rest become quiescent ? These are important questions, to which, however, a satisfactory answer can hardly be given in the present state of our knowledge. The insensibility induced by extreme cold may perhaps be so explained. The subject altogether merits consideration. The prognosis in apoplexy is governed, in some measure, by the actual condition of the brain, and also by the nature of the remote cause, and the possibility of its removal. This will be best un- derstood when we come to the particular treat- ment of the disease under its different circum- stances. It may be observed in general, that a very large proportion of cases of apoplexy termi- nate fatally ; some of them immediately, some after a longer interval. Those that do not prove immediately destructive to life, are often fatal on recurrence, though repeated attacks may inter- vene. Cases that depend upon vascular excite- ment merely, without lesion of structure, and without extravasation of blood, or accumulation of serum in the brain, may be judged of favour- ably. But as these points can seldom be deter- mined with certainty during life, the prognosis in apoplexy is always more or less doubtful, and for the most part unfavourable. Treatment. — There is perhaps no disease the treatment of which requires so much to be directed by theory or general principles as apo- plexy. The practice in general use is, for the most part, unnecessarily violent; and, in some respects, contradictory. Bloodletting to an un- reasonable extent, vomiting, purging, blistering, sinapisms, and a variety of other stimulants, have all been administered with an almost indiscrimi- nate and unsparing hand ; as if, to insure re- covery, it were only necessary to have recourse to sufficiently active means, without much regard being paid to their nature or effects. The treat- ment thus becomes needlessly complicated and severe ; and there is reason to believe that the end sought after is often thereby frustrated rather than promoted. It is necessary, in order to practise with success, to look not only to the symptoms, but to the intrinsic nature qf the affection; and more especially to the various remote causes by which the disease may be induced, the obviating of which is the principal object of attention in the cure. Without these distinctions being made, the treatment becomes little more than empirical. It is above all things necessary to guard against the profuse and almost unqualified use that is made of the lancet on those occasions, apparently without consideration of what it may be really capable of effecting, and what it is incompetent to perform. By injudicious application, it will not only fail to do good, but may impede recovery, and even tend to destroy life. Admitting that the proximate or immediate cause of apoplexy in general, as far at least as this is understood, is impeded or interrupted cir- culation of blood in the brain, the simple and obvious indication of cure to be followed, is to restore the circulation so obstructed ; which is in general only to be accomplished by the removal of the obstructing cause. This being various, and different at different times, may require dif- ferent and even opposite means for its removal. It becomes necessary, therefore, to show the in- dividual treatment of apoplexy, in relation to its exciting or occasional cause ; and'for this purpose it will be useful to follow the order laid down in speaking of the various remote causes of the dis- ease. These may be usefully arranged under three heads, viz..- 1st, such as act by mechanical pressure on the brain; 2d, such as act by pro- ducing arterial excitement and distension; and, 3d, such as occasion impediments to the return of blood from the brain by the veins. 1. Treatment of apoplexy in reference to the first division of causes.—When apoplexy is in- duced by fracture of the skull with depression, or where blood is effused immediately beneath the bone, the treatment is simple; consisting prin- cipally in the elevation or removal of the depress- ed portion of bone. The means of accomplish- ing this are within the province of surgery. The after-treatment consists in endeavouring to pre- vent and to remove inflammation by bloodletting and other analogous remedies. An interruption or suspension of the sensorial functions may take place as the result of external violence, in which there is no injury done to the bone, nor other source of pressure on the brain. This has been referred to concussion simply, or the shock which the organ has sustained from the fall or blow received. The injury done to the brain in some of these cases is so great, as to prove immediately or quickly fatal; and yet, upon dissection, nothing has been found adequate to explain the effect. At other times, vessels have 152 APOPLEXY, (CEREBRAL) been ruptured, and blood found effused, sufficient to explain the apoplectic state. It is not possible, at all times, to distinguish, during life, between the effects of simple concussion, and those arising from the pressure of extravasated blood in the brain ; and the difficulty is the greater from the circumstance, that the case is often complicated ; the same degree of violence that occasioned a rupture of blood-vessels, almost of necessity pro- ducing a considerable shock to the brain. The distinction, in regard to symptoms, that has been supposed to exist in the two cases of concussion and extravasation, is by no means to be relied upon. Still less does there appear to be a foun- dation for the widely-different methods of cure, that have been proposed with respect to them. The older writers on surgery relied principally upon bloodletting in cases of supposed concussion, as well as in other injuries of the brain. The moderns, some of them at least, influenced pro- bably more by love of novelty than real observa- tion, condemn in toto the practice of bloodletting, and recommend, instead of it, a totally opposite mode of cure; namely, the use of opiates and general stimulants. In neither case does the view that has been taken of the subject appear to be altogether correct; nor is the practice recommend- ed at all times consistent with reason. Experi- ence, which has been adduced in favour of both modes of practice, cannot be implicitly relied upon. Upon the supposition that the brain has suffered only from the shock, without depression of bone, or extravasation of blood, it is not con- ceivable that bloodletting should be capable of affording any immediate relief. The medullary substance may have been deranged, or have un- dergone an imperceptible solution of continuity in the minuter parts of its structure ; or its vital properties may have been simply affected, without physical or mechanical injury; but in neither case is bloodletting an indispensable remedy. There is one point of view, however, in which blood- letting may be considered of importance; and that is, in regard to its power of preventing in- flammation, which is an almost necessary conse- quence of such violence committed on the brain. The propriety of bloodletting, however, will still be to be governed by circumstances, and especial- ly by the state of the general vascular action ; which differs considerably in different instances. In some cases of simple concussion of the brain, the general circulation is carried on very feebly ; the pulse is weak and soft, with varying fre- quency ; and the body is cold. Such a state can hardly be supposed to require, or even to bear, loss of blood. At other times, the action of the general vascular system is little altered from the natural state. In such cases, the moderate ab- straction of blood would be safe and proper, as a means of preventing subsequent inflammation. It is scarcely necessary to add, that if the pulse at the wrist is fuller or stronger than natural, (as may be the case from the first, or it may take place at some period after the infliction of the injury,) there need be no hesitation as to the free abstraction of blood; limited, of course, by the general strength and other circumstances of the patient. But admitting that bloodletting is not required in any particular case of concussion of the brain, does it follow that opiates or stimulant! should be proper ? What possible tendency can either of these have to relieve the injury which the brain has sustained, either with regard to its physical or vital properties ? Even should the general circulation be greatly depressed, still it is not easy to see how exciting it by active stimu« lants should be productive of much good, as they are not likely to produce lasting good effects, nor have they any tendency to remove the cause; namely, the injury the brain has suffered. On the other hand, if largely used, they may increase the tendency to inflammation, and thus become objectionable. Upon the whole, except the em- ployment of bloodletting in the circumstances and with the view now mentioned, the variety of apo- plexy that results from what is termed concussion of the brain, admits only of very simple treat- ment. With the exception of inflammation, the prevention and cure of which are objects of great importance, relief can only be hoped for from time, and a quiet state of the organ. Apoplexy arising from the extravasation of blood in the brain, (that form of the disease which has attracted the greatest notice,) cannot be cer- tainly known during life, though it may often be suspected. When the disease occurs suddenly and with violence ; or, beginning mildly, gradu- ally gets worse; and when the stupor continues for many hours, and is then followed by only an alleviation of symptoms; there is strong ground for believing that a rupture of blood-vessels has taken place in the brain. This is a case in which bloodletting has been used with little discrimina- tion, and often, there is reason to believe, carried to a hurtful excess. It is evident that the remedy can have no direct effect in removing the extrava- sated blood; nor can it lessen the quantity of blood altogether within the skull, so as to give ad- ditional space, and thereby diminish the pressure the effused blood is making on the brain; and yet it is employed in these cases as if it were car pable of accomplishing, with certainty, one or other of these purposes ; it is used too with such freedom, as if it needed only to be carried to a certain extent in order to insure success. But blood, once extravasated, can be removed only by absorption, which is a natural and slow process, requiring for its completion at least a moderate share of general strength. Large and unnecessary abstraction of blood in such cases, by weakening the body altogether, rather creates an obstacle to recovery than the contrary. The proper use of bleeding in such cases is, to reduce that violence of arterial action in the brain (often of a real in- flammatory nature) upon which the rupture and effusion immediately depend, and thereby to pre- vent a further escape of blood. But for such a pur- pose, only a moderate though perhaps repeated ab- straction of blood can be required; and then always in proportion to the age and other circumstances of the patient, and according to the stage and duration of the disease. As mere matter of expe- rience, there is reason to believe that bloodletting in these cases does much less good, and the omis- sion of it less injury, than is generally supposed. As to the other remedies in general use on these occasions, little can be said in their favour, while some of them are decidedly hurtful in their ten- APOPLEXY, (CEREBRAL) 153 dencies : such is the case with extensive blister- ing, or sinapisms, and internal stimulants of any considerable activity. From the very nature of the case, they can accomplish nothing beneficial; while the immoderate use of them may do harm, by exciting the general vascular action of the sys- tem. Vomiting is for the most part objectionable, and may be even dangerous, by the temporary check it gives to the return of blood from the head. Even where it is known or suspected that the stomach is in a loaded state, the danger at- tending full vomiting is more than a counterpoise to any benefit likely to be derived from the prac- tice. Sneezing, which has been sometimes re- commended for the relief of the stupor, is little less hazardous than the use of emetics. The treatment of apoplexy dependent upon ac- cumulation of serous fluid in the brain, or, as it is termed, serous apoplexy, requires a further con- sideration. It has been already stated that no ab- solute line of distinction can be drawn between the sanguineous and serous forms of the disease ; they are, in fact, frequently found in combination, or rather to be considered as mere varieties of one and the same affection. Serous accumulations in any of the cavities of the body are in most in- stances the result of membranous inflammation ; not in general of an acute, but rather of a chronic or protracted description. This primary depend- ence of serous accumulations, or dropsies as they are called, on inflammation, is not always distinct- ly seen, on account of the mildness of the inflam- matory symptoms at first, and their having often passed away without notice, leaving the accumu- lation of fluid behind. Still, there are but few cases in which the connexion of dropsy with in- flammation, as its primary source, may not be traced by accurate inquiry. This applies to the brain, as much as to either of the other cavities. In most apoplexies that come on slowly, and which, on this account, are supposed to be of a serous nature, signs of preceding as well as of existing inflammation in the cavity may be dis- covered ; such as head-achs, sometimes accompa- nied with flushing and throbbing of the arteries about the head; together with more or less of general febrile action throughout the system, (which last is to be taken as an infallible criterion of the existence of topical inflammation in some organ,) to say nothing of the disturbance of func- tions which marks the seat of the disease. Mere serous accumulations, without other disease of the organ, may account for a lethargic state of the pa- tient, but is hardly sufficient to explain the oc- currence of an apoplectic fit; which, being sudden in its attack, and disposed to recur by paroxysms, must depend upon some occasional and temporary cause, and not upon the mere presence of the fluid ; for this must be slowly collected, and when once formed must be permanent, or, at all events, is not likely to be rapidly absorbed. No tempo- rary cause of such disturbance, or rather suspen- sion, of functions as takes place in apoplexy can be suggested with so much probability as occa- sional arterial excitement, to which the brain ap- pears to be particularly prone. Such a disposi- tion to occasional arterial excitement is a natural consequence of inflammation, and may remain long after the inflammation which gave rise to it Vol. I. — 20 has disappeared. And thus it is that persons liable to apoplexy of this mild description, suffer a great number of slight attacks with impunity ; but in general are at length carried off by one of greater violence; and then it is usually found, upon examination after death, that extravasation of blood has produced the fatal event; proving that there is no real or essential distinction to be made between serous and sanguineous apoplexy. In the treatment of apoplexy of this nature, slow in its approaches, and occurring, as it occa- sionally does, in feeble habits, a mild plan of cure only is admissible. Inquiry is to be made as to the probable existence of inflammation, its degree and duration ; and remedies applied accordingly. In no case, even during the fit, could a large ab- straction of blood be proper. Such a remedy, supposing the fit to be the immediate result of arterial excitement merely, without a rupture of vessels, is unnecessary, as the increased vascular action will probably subside by milder means, or even spontaneously ; while, should effusion have actually taken place, the largest bloodletting could effect nothing direct towards its removal, and might even prove immediately fatal. At all events, the patient would be left in a less favour- able state for future recovery. It is here as in epilepsy, in which, during the paroxysm, unless the disease altogether be of recent occurrence, little can be done with advantage. It is in the inter- vals, for the most part, that we can hope the mea- sures adopted will be permanently advantageous. So in apoplexy, of the description here alluded to, the paroxysm, however alarming in appearance, is either of no real importance, or, if it should be dangerous from rupture of vessels, or other injury sustained by the part, art can do little or nothing for its relief. In the intervals, and when a sus- picion of inflammation no longer exists, it may be proper to aim at removing the serous deposit, by diuretics or other such methods as are not par- ticularly detrimental to the general health. In this point of view, the employment of mercury, however highly vaunted on these occasions is of very equivocal use. Serous accumulation in the brain appears to take place at times, as a consequence of impedi- ments to the return of blood by the veins : hence the stupor that is observed to occur in some pul- monary affections, in which the blood is not trans- mitted with freedom through the lungs. This, however, is rather lethargy than apoplexy, as it does not occur by fits, unless there should be actually at the same time disease in the brain itself. With respect to tumours, or other alterations of structure, observed in the brain of persons dying of apoplexy, such are to be considered rather as predisposing, and not as efficient, causes of the apoplectic state. Being permanent in their nature when once formed, they can afford of themselves no adequate explanation of a paroxysm or fit that is only of occasional occurrence. This, as was observed on a former occasion, must be referred to temporary vascular excitement, the disposition to which is produced and kept up by the presence of the morbid structure. Apoplexy may be sus- pected to be of this nature, when preceded or ac- companied by symptoms denoting the existence 154 APOPLEXY (CEREBRAL) of chronic inflammation in the brain. These mor- bid changes of structure are generally found in combination with more or less of serous effusion. Should apoplexy take place under such circum- stances, bloodletting might be required for the im- mediate relief of the fit, but not to any great ex- tent ; the object being merely to diminish the arte- rial action of the brain, and thereby to put a stop to that temporary state of excitement which is the immediate cause of the paroxysm. In this, as in other cases, sanguineous effusion may have taken place; but of this no certain knowledge can be obtained till after death. If it were even possible to ascertain it during life, it would afford no additional ground for profuse bloodletting. Should the patient survive the fit, it is then an important object to endeavour to remedy the dis- organization which we may suspect to exist in the brain, or rather to take off the inflammatory action in the part, which has produced the alteration of structure; for over the morbid structure itself art has little influence. It is, however, only in slight and recent affections of the sort, that we can hope to be successful; though much may still be done to mitigate and to check the further progress of the mischief. The means we have it in our power to employ for the purpose are few and sim- ple. Small and repeated bloodlettings afford the best, if not the sole chance of success in such cases. To enable the patient to bear these for as long a period as may be necessary to accomplish the purpose, it is indispensable that he be allowed to take food in reasonable quantity, and of the most simple digestible kind. There is no better guide, perhaps, on these occasions, than the natu- ral appetite, when not excited by variety or by food of a stimulant nature. It is a great mistake to suppose, either in this or in other chronic dis- eases requiring bloodletting, that the attainment of our object is likely to be frustrated by a mode- rate use of food, whether animal or vegetable in its nature. Judging from experience in chronic forms of inflammation, the contrary rather appears to be the case. An unfounded preference appears to be given to what is called local or topical bleed- ing over venesection. The term topical or local is quite misapplied here, as no vessel immediately connected with the brain, or that can directly in- fluence its circulation, admits of being opened for the purpose of letting blood. It is to quan- tity, and the rapidity of taking away blood, that we are to look, and not the part from which the blood is taken ; unless indeed it could be drawn immediately from the part affected ; which is of course impracticable. The circulation of the dis- eased part, as far as regards the abstraction of blood, can only be influenced through the medium of the general circulation ; and this we can more readily and effectually act upon by venesection or general bloodletting, than by what is termed local bleeding; simply because we have a command, both as to time and quantity, in the one case, which we seldom can have in the other. The safety of bloodletting, in both modes, depends upon quantity ; but not so the efficacy of the practice. [t might not indeed be prudent, or even safe, in all cases, to abstract blood so rapidly as to induce fainting. In general, this had better be avoided ; ' both as being seldom necessary, and as generally j alarming in appearance. ' The other means in use for the treatment of chronic inflammatory disease in the brain, such as I purgation and counter-irritation by blisters, issues, or the like, are of very inferior importance in com- i parison with bloodletting, in cases admitting of the latter. A long-continued and rather severe employment of mercury has to all appearance been attended with success in many instances ; but in many also it has failed. In the use of it, we are not to forget its power of doing harm as well as good. The treatment of the second order of apoplexies, those that arise simply from high arterial action and distension of the vessels of the brain, without extravasation or serous effusion, and without dis- organization, is of a simpler kind, and more likely to be attended with success. Ordinary cases of intoxication, from the excessive use of strong drinks, in general require only quiet and Tepose for a few hours; in the course of which the vascu- lar action of the brain subsides into its natural state, and often indeed falls below it, so that a ■ stimulus of the same kind afterwards is found to relieve the feelings of depression that generally succeed. In aggravated cases, however, of this description, and especially in persons unaccustomed to the use of strong drinks, more active measures may be called for ; such as bloodletting to a mode- rate extent, and purging, in order to subdue, more quickly and effectually, the vascular excitement of the brain. These should be accompanied with the moderate application of cold to the head, with a view both to its sedative and its constringing properties, in the hope that these effects may be communicated by sympathy from the external to ' the internal vessels of the head. There is another | good reason for the employment of such means in aggravated cases of intoxication, namely, that of guarding against inflammation of the brain, which now and then results from this cause. When the narcotic effects of opium and drugs ' of the same class occur in an alarming degree, a I very similar mode of treatment is required. In regard to the use of bloodletting in both cases, attention must be paid to the state of the general circulation. A soft and feeble pulse, with cold extremities, would not admit of bloodletting, but might require, on the contrary, the use of simple stimulants, such as ammonia, together with fric- tions and external warmth. Heat of the head, and throbbing of arteries, which are often found, even where the surface and extremities are much chilled, call for the application of cold to the head, as well as in the case of intoxication. The prac- tice generally inculcated, in cases of poisoning by opium, is to endeavour to keep the patient from falling asleep, by every possible mode of irritation; if such treatment be proper in the case of opium. one does not see why it should not be also adopted in cases of intoxication by alcohol; for the symp- toms are nearly alike in the two cases. If the stupor or suspension of the sensorial functions produced by narcotic substances be owing to an excited and distended state of the arteries of the brain, irritation of any kind will only prove an additional cause of vascular excitement in the APOPLEXY, (CEREBRAL AND PULMONARY) 155 brain. It would be well if a satisfactory appeal could be made to experience, in order to decide the point of practice : but this can hardly be done, on account of the difference which exists between different cases. Should the apoplectic state have been occasioned by isolation, the hot bath, or mental excitement the treatment is simple. Moderate loss of blood, purgation, and the application of cold to the head, would seem to comprise all that can be really useful. If, after the lapse of a few hours, con- sciousness should not return, the probability will be that the violence of arterial action in the brain has been followed by the extravasation of blood ; the proper management of which has been already pointed out Apoplexy is not an unfrequent consequence of inflammation of the brain, whether this exist in the form of membranous inflammation (hydro- cephalus acutus of infants); of phrenitis; or of idiopathic fever, so called. In each of these cases, when so violent as to threaten a fatal termination, a comatose state bordering on apoplexy takes place ; the apoplectic symptoms being mixed up with and modified by those of inflammation. This termination of inflammation of the brain it is not difficult to understand. In the early stage of those affections, the vascular excitement of the brain is moderate in degree, and not attended with any considerable distension of vessels. The circulation then is not materially impeded, and the functions of the organ are still carried on, though in an excited and disordered way. In the further pro- gress of the disease, the distension of arteries in- creases ; the circulation is by degrees obstructed ; and this is soon followed by an interruption, first, of the primary functions of the brain, sensation, voluntary motion, and intellect; next, the vital functions, respiration, and the general circulation suffer, and life becomes extinct. The treatment requisite in all these cases is the same ; namely, that which is adapted to subdue inflammation in general; regulated, however, by the circumstances of the patient, and most particularly by the stage of the disease. When the apoplectic state shows itself early, there is no question as to the propriety of bloodletting, and that with freedom. In an advanced stage, and especially when the general circulation is failing, this remedy becomes equivo- cal, and must be used, if at all, with reserve and caution. The third variety of apoplexy, namely, that which arises from an interruption to the return of blood from the brain, requires a different mode of treatment from the others, on account of the diffe- rent nature of the causes producing it. This is the state to which the term venous congestion has been applied, but which is nothing more than stagnation of blood in the cerebral vessels, a state which must necessarily take place if the returning current of blood by the veins be impeded or inter- rupted. As this interruption may be produced by different causes, there will be some difference in the treatment. In the simplest case of impeded return of blood from the brain, that occasioned by a dependent posture of the head, all that is com- monly required is to raise the head. Should the stupor be occasioned by tumours in the neck, or in the course of the veins towards the heart, our being able to give effectual relief will depend upon our ability to remove or lessen the obstructing cause. In the case of violent and extensive in- flammation of the lungs, where, from the swelling of parts, the blood finds its way sparingly and with great difficulty through the lungs, the impedi- ment to the return of blood from the head, as well as other parts, is seen in the livid hue of the cheeks and lips, in the bloated state of the face and neck, and in the stupor, or imperfect performance of the sensorial functions. Along with these, the pulse at the wrist becomes soft, feeble, and often irregu- lar ; and the extremities cold. Such a state of things is nearly hopeless ; for it scarcely admits of relief from art The feeble state of the general circulation will hardly admit of loss of blood; while there are no other means that promise a better result. The practice of giving stimulants on those occasions, merely because the pulse is weak, and because bloodletting is not admissible, is supported neither by reason nor by experience : such practice is, in fact, in opposition to both. In the more chronic cases of obstructed circula- tion, arising from disease about the heart and lungs, a disposition to apoplexy is gradually formed, which may destroy the patient, if he is not previously cut off by the primary disease. Apoplexy thus induced is commonly of the serous kind ; it takes place slowly, from effusion conse- quent upon long-continued impeded circulation in the brain, and rarely admits of remedy. If, how- ever, the primary disease in the heart or lungs is in a favourable state for the employment of reme- dies ; that is, if the inflammation be not of very long standing, the organization not materially deranged, nor the general strength much impaired, there is still a chance that a cautiously-conducted plan of treatment, adapted to the relief of chronic inflammation, such as has been pointed out above, may rescue the patient from destruction. A result so favourable, however, is seldom to be expected. H. Clutterbuck. APOPLEXY, Pulmonary. The term pul- monary apoplexy has been adopted by modern pathologists to signify an effusion of blood into the parenchymatous substance of the lung, in consequence of the resemblance which this lesion bears to the extravasation of blood into the sub- stance of the brain in cerebral apoplexy. But as the name of apoplexy was originally applied to a determinate group of symptoms, not to any par- ticular form of organic lesion, we evidently divert this term from its original signification in thus making it synonymous with the effusion of blood into the tissue of an organ. However, as the term has been sanctioned by the high authority of Laennec, and is now generally adopted by pathologists, it may be as well to retain it, though certainly objectionable, as to encumber our noso- logical nomenclature with the term pneumo- hemorrhagia, recently proposed by Andral, as more aptly expressing the nature and seat of the disease, while it establishes a contrast with the term broncho-hemorrhagia, by which he proposes to designate the exhalation of blood from the lining membrane of the bronchial tubes. For a long period, the rupture of a vessel was the only .souice of pulmonary hemorrhage recog- 158 APOPLEXY, (PULMONARY) nised by pathologists; and even at the present day, the expression of bursting a blood-vessel on the lungs is used by many as synonymous with Haemoptysis. The cultivation of morbid anatomy has, however, tended to correct this as well as many other popular errors, and has fully estab- lished that, in a large proportion of cases, the source of the hemorrhage is to be found in a sim- ple exhalation from the lining membrane of the bronchia. "I have repeatedly opened," says Bichat, " the bodies of persons who died during an attack of haemoptysis, and though I examined the surface of their bronchial membrane with the greatest care, and even took the precaution of allowing it to macerate for some days before examining it with a lens, I have never been able to detect the slightest appearance of erosion, or of the rupture of a vessel." Another source of pulmonary hemorrhage has still more recently been described by the author of the well-known treatise on Mediate Ausculta- tion, who states, " that while the greater number of slight or moderate haemoptyses consist in a simple exhalation of blood from the lining mem- brane of the bronchial tubes, the severer cases 01 iginate from a different source, and come chiefly from the vesicular structure of the lungs :" and this latter is the variety of hemorrhage to which he applies the name of pulmonary apoplexy. It is true that this affection had been noticed by earlier writers, and even described under its pre- sent name. Haller, in his Opuscula Pathologica, gives a brief and melancholy account of the death of a friend, who fell a victim to this disease; his description of the morbid appearances, though general, is sufficiently characteristic of the disease: " In pulmone utroque, non inflammatio, non ulcus, sed sanguinis universalis effusio fuit, ut sudore sanguineo in cellulosam fabricam effuso, et sensim collecto, nigerrima demum magna pars visuris esset" M. Lereille read a memoir on the subject before the Academy of Sciences in the year 1816; and Doctor Hohntaum published an essay on pul- monary apoplexy at Erlangen in 1817. M. Laen- nec's treatise was not published until 1819 : however, as the affection was entirely unknown as a common cause of haemoptysis before the pub- lication of his work, and as no preceding writer had given its precise anatomical characters, the merit of having first accurately described the dis- ease must be accorded to Laennec, even though the more equivocal merit of its denomination may be contested by others. Apoplexy of the lung, like that of the brain, presents considerable variety in the symptoms it produces during life, and the anatomical charac- ters it presents after death ; for whilst in some in- stances it produces no other inconvenience than the expectoration of a few ounces of blood, it in other cases proves as instantaneously fatal as the most violent attack of cerebral apoplexy. Neither are its anatomical characters less variable; for, while in its milder form its effects are limited to the sanguineous infiltration of the air-cells of one or two lobules, it occasionally pours such a deluge of blood into the substance of tho lung, that the delicate structure of the organ is broken down before it, and even its investing membrane, the pleura, is ruptured by the violence of the hemor- rhage. The anatomical characters of pulmonary apo- plexy as described by Laennec, are, a remarkable induration of the pulmonary substance, equal to that of the completest hepatization : the indura- tion, however, is very different from the inflamma- tory affection of the lungs distinguished by this term. It is always partial, and rarely ever occu- pies a considerable portion of the lungs: its more ordinary extent being from one to four cubic inches. It is almost always very exactly circum- scribed, the induration being as considerable at the very point of termination as in the centre. The pulmonary tissue around is quite sound and crepi* tous, and has no appearance whatever of that pro- gressive induration found in pneumonia. The substance of the lung is indeed often very pale around the haemoptysical induration ; sometimes, however, it is rose-coloured, or even red, as if tinged with fresh blood ; but even in this case the circumscription of the indurated part is equally distinct. The indurated portion is of a very dark red, exactly like that of a clot of venous blood. When cut into, the surface of the incisions is granulated as in a hepatized lung; but in their other characters these two kinds of pulmonic in- duration are entirely different. In the second degree of hepatization, we can perceive distinctly the black pulmonary spots, the blood-vessels, and the fine cellular intersectures, all of which together give to this morbid state fhe aspect of certain kinds of granite. In the induration of haemopty- sis, on the contrary, the diseased part appears quite homogeneous, being altogether black or of a very deep brown, and disclosing nothing of the natural texture of the part, except the bronchial tubes and the larger blood-vessels. The latter have even lost their natural colour, and are stained with blood. In scraping the incised surfaces of their parts, we can detach a small portion of very dark half congealed blood, but in a much less propor- tion than we can press out the bloody serum from a hepatized lung. We sometimes find two or three similar indurations in the same lung, and frequently both lungs are affected at the same time. (Laennec on Diseases of the Chest, translated by Dr. Forbes.) Nothing can exceed the accuracy of this de- scription, but it only applies to the milder form of the disease, when the extravasated blood is effused into the air-cells of one or more lobules, and the individual survives for a sufficient length of time, to have the fluid portion of the extravasation com- pletely absorbed. This condition of the lung may be termed its hxmoptoic engorgement, to distin- guish it from another form of the disease, in which the blood, instead of simply accumulating within the air-cells, ruptures their delicate parietes, breaks down the structure of the lung, and is extravasated into the lacerated tissue. It is to this form of the disease that the name of pulmonary apoplexy is more strictly applicable, as beinir most analogous to the condition of parts which exists in cerebral apoplexy. This form of the disease seems to differ from the haemoptoic engorgement only in decree, the laceration of the parenchyma of the lung, and the APOPLEXY, (PULMONARY) 157 consequent extravasation of blood, being caused by the over-distension and rupture of the air-cells, from the excessive quantity of blood which is poured into them. Accordingly, when the haemop- toic engorgement is extensive, or takes place sud- denly, and with violence, we generally find its interior broken down, and occupied by extrava- sated blood. In a young man who died of organic disease of the heart in the Whitworth Chronic Hospital, after experiencing a violent attack of haemoptysis about a week before his death, we found the lower lobe of the right lung occupied by a mass of haemoptoic engorgement as large as an orange, and containing in its centre a clot of dark-coloured blood of the size of a hazle-nut; the cavity in which this clot was contained, had evidently been formed at the expense of the pul- monary parenchyma. Laennec alludes to this form of the disease in the passage, where, de- scribing the haemoptoic engorgement, he says, " sometimes the centre of these indurated masses is soft, and filled with a clot of pure blood." An- dral has likewise noticed this variety of the disease in his treatise on pathological anatomy. In some cases the quantity of blood effused is much larger, and a greater extent of the pulmo- nary parenchyma is broken down, so that a con- siderable portion of the lung is reduced to a soft fluctuating mass, in which there can only be dis- tinguished some remains of the parenchymatous structure of the lung, and a quantity of effused blood, partly fluid, and partly coagulated, as in the case recorded by Corvisart (Commentaires sur la Trait'e de la Percussion) of a young man who retired to rest apparently in perfect health, and was found dead in his bed the next morning with blood streaming from his mouth and nose. On dissection, the interior of the right lung was found torn and ruptured in every direction, and gorged with an enormous quantity of dark-coloured blood; the bronchial tubes were likewise filled with the same fluid, as were also the trachea, and larynx, the throat, and the posterior nares. As examples of such extensive rupture and disorgan- ization of the pulmonary parenchyma from extra- vasation of blood are of rare occurrence, we shall briefly transcribe a case of this description, which fell under our notice in the Hardwick Fever Hos- pital. A young delicate-looking man in an ad- vanced stage of fever stooped out of bed to take up his spitting-pot, which had fallen ; while in the act of stooping, he became giddy, lost all con- sciousness, and fell on the floor; he remained insensible for some minutes, but after throwing up a large quantity of blood, he recovered so far as to ask for a drink of water; he drank with avidity, and again relapsed into a state of apparent insensibility, and died within an hour, discharging a quantity of blood from his mouth and nose. On dissection, which was made in eighteen hours after death, all the air-passages from the mouth to the lungs were found filled with dark fluid blood. The right lung did not collapse when the chest was opened, except its upper lobe, which appeared healthy and of its natural colour : the middle and lower lobes were externally of a uniform deep red colour, and when pressed under the finger con- veyed a distinct sense of fluctuation. When cut into, a quantity of fluid blood rushed out, bearing o along with it a number of grumous clots, and several masses of broken-down pulmonary tissue. The interior of the lung presented a shreddy appearance, and resembled a sponge which had been steeped to saturation in blood. The anatomical characters of this form of pul- monary apoplexy differ materially from those de- scribed by Laennec. The seat of the disease, instead of being circumscribed, solid, and present- ing a granular surface, when cut, is perfectly un- circumscribed, feels soft and fluctuating to the touch, and when cut into, exhibits a mixture of fluid and clotted blood infiltrated through the parenchyma of the lung, which is ruptured and broken down. These differences may, however, be satisfactorily accounted for : in the haemoptoic engorgement, as described by Laennec, the cir- cumscribed, solid, dark-coloured masses, varying in size from one to four inches, are evidently caused by the infiltration of the blood into the air- cells of the part, and its coagulation there ; as any one may satisfy himself by examining in the strong light of the sun the granular surface, which a section of the part exhibits, and by scraping it gently with a scalpel, so as to turn out the little rounded coagula from the cells in which they are moulded, after which the part will exhibit a dis- tinct cellular structure, exactly resembling a sec- tion of the corpus cavernosum penis. The reason of the lesion being in general so accurately cir- cumscribed, is, that the cellular tissue which invests and isolates each lobule prevents the escape of the effused blood into the adjoining lobules. The solidity of the part proceeds from the serous portion of the blood being absorbed, and the fibrinous coagulum becoming intimately combined with the tissue of the part; for in those cases where death occurs soon after the hemor- rhage, the blood is uniformly found in the fluid state : and lastly, the dark colour which the hae- moptoic induration presents, may be accounted for by the stagnation of the extravasated blood, which uniformly produces this effect, as in the familiar example of an external contusion, and in Hunter's well-known experiment of intercepting a portion of artery between two ligatures, and finding, after a certain time, that the blood thus confined had lost its arterial colour, and assumed a dark venous hue. In this form of the disease there is no solu- tion of continuity, no breaking down of the pul- monary tissue, but simply an infiltration of blood into the spongy texture of the part. But if the texture of the organ is less resisting, or the force of the infiltrating fluid more irresisti- ble, the pulmonary structure gives way, and the interlobular partitions which served to bound the progress of the effusion being broken down, it ceases to be circumscribed. In this form of the disease the blood is seldom wholly coagulated, and we believe never so perfectly as in the haemoptoic engorgement For this fact, several satisfactory reasons may be assigned. In the first place, when the hemorrhage is so violent, death generally fol- lows before the blood has had sufficient time to coagulate perfectly, and to have its aqueous parts absorbed. It generally happens also that those extensive hemorrhages are connected with a pecu- liar liquid state of the circulating fluid, which diminishes its tendency to coagulate, and disposes 158 APOPLEXY, ( PULMONARY) it to pass off more freely by the exhalents, as in cases of scurvy, purpura, &c. Besides which, we may suppose that blood when effused in a large mass is not as favourably circumscribed for having its thinner part absorbed, as when minutely sub- divided, and each division placed in contact with so active an absorbing surface as the walls of the air-cells. Another variety of pulmonary apoplexy is that in which the hemorrhage not only breaks down the parenchymatous structure of the lung, but likewise ruptures its investing membrane, and bursts into the pleural sac. This is by far the rarest form of the disease ; we have never seen an example of it, nor have we been able to dis- cover more than four cases of it on record. 1. The first is related by Corvisart (op. cit). Dr. Fortassin was found dead in his bed one morning after having retired to rest the preceding evening in the apparent enjoyment of excellent health. On dissection, the right pleural sac was found filled with coagulated blood, the interior of the right lung was also gorged with it, and its surface exhibited several rents, which extended to a considerable depth within its substance. In this case death occurred suddenly, and was not pre- ceded by or accompanied with haemoptysis. 2. In an analogous case, published by M. Bagh, in the Revue Medicale, the patient was suddenly seized with violent dyspnoea : his face became pale, the pulse almost imperceptible, and death super- vened in a few minutes after the commencement of the attack. A quantity of bloody serum was found effused into the left side of the chest, and with it about a pint of dark clotted blood, which evidently came from a rupture in the base of the lung, the inte- rior of which was lacerated and broken down, as the substance of the brain is in cerebral apoplexy. 3. The third example of this form of the dis- ease is recorded by Andral, (Clinique Medicale,) in the case of a middle-aged man, who presented the ordinary symptoms of pulmonary consump- tion, attended with a slight degree of dyspnoea. One morning he was found breathing with much greater difficulty than usual, and his sputa were observed to be slightly tinged with blood : during the two succeeding days his difficulty of breathing increased considerably, the sputa became more deeply tinged with blood, and he died in an ex- treme state of dyspnoea. On dissection a quantity of blood and serum was found in the left pleura, the surface of the left lung was ruptured, the size of the rupture being about an inch in diameter. When the lung was laid open, a space as large as an orange was found, corresponding with the rent on the surface, and occupied by fragments of torn pulmonary tissue, mixed up with a dark gru- mous blood. 4. The fourth and last case of this description on record is that recently published by Dr. J. C. Ferguson, in the first volume of the Dublin Medi- cal Transactions. A robust man, oet 36, who had occasionally suffered from attacks of consti- pation and bronchitis, complained, on the 19th of June, 1829, that his cough was increased, his chest somewhat oppressed, and his expectoration, since the day preceding, slightly tinged with blood; his countenance was pale, his pulse about 90, and feeble, and his skin covered with a cold clammy perspiration. On the next day he felt relieved by the operation of a purgative. During the suc- ceeding night he was rather restless ; however he ate his breakfast as usual, and while in the act of stooping to put on his shoes, he complained to his wife of loss of vision, seemed to faint and died without a struggle. Examination made forty- eight hours after death :—the left pleural sac con- tained about three quarts of blood, the serum su- pernatant, as in blood allowed to stand after vene- section, and the clot in considerable quantity, but very soft, occupying the most dependent portion of the cavity. The lung had contracted no adhe- sion ; the superior lobe was one mass of the most perfect pulmonary apoplexy, the structure of the lung seeming to be actually broken up by the ex- cessive effusion of blood into it; the apoplectic mass was soft and flabby ; it would scarcely bear to be incised, but broke down easily under the finger or scalpel. On the superior and posterior part of the affected lobe a laceration of the invest- ing pleura was found, about one inch in length and half an inch in breadth, with very irregular edges, and immediately over the point where the sanguineous effusion into the substance of the lung seemed most intense, and where we might naturally expect the greatest violence to be oppos- ed to its serous covering. A remarkable fact in the history of this case was, that he had expecto- rated no blood for fourteen hours before death, nor in the agony was there any escape of blood from the mouth or nares which might lead to a suspi- cion of the real seat of the disease. The same remark is also applicable to the preceding cases, Nos. 1 and 2, in which no haemoptysis whatever took place before death, and the cause of the fatal catastrophe was only discovered on dissection. The etiology of this disease is still involved in considerable obscurity. In fact, we know as little of the peculiar modification which the texture of the lung undergoes when it allows the blood deter- mined towards it to escape from its vessels, as we do of the changes which these vessels undergo when at one time they secrete pus, and at another exhale a thin serous fluid. Andral supposes that pulmonary apoplexy differs from bronchial hemor- rhage only in its situation, the former being caused by exhalation from the lining membrane of the air-cells, as the latter is by exhalation from the lining membrane of the bronchia ; in fact, he sup- poses that pulmonary apoplexy is to bronchial he- morrhage what pneumonia is to bronchitis, — a similar disease affecting the ultimate ramifications of the bronchia instead of their primary divisions. He is likewise of opinion that in a large propor- tion of cases the morbid alteration to which the name of pulmonary apoplexy is applied, should not be regarded as the only source of all the blood which had been expectorated during life ; on the contrary, he believes that the hemorrhage gene- rally proceeds from a much larger surface of the mucous membrane, and that the dark indurated patches of pulmonary apoplexy are caused by the blood accumulating in those points whilst it was removed from the other parts of the bleeding sur- face, and expectorated as fast as it was effused there. By adopting this view of the subject, we are enabled to understand those cases of violent APOPLEXY, (PULMONARY) 159 and profuse haemoptysis, in which, after death, the extent of the haemoptoic engorgement is found very small, and not at all commensurate with the quantity of blood which had been expectorated during life. The quantity of blood discharged in this way is sometimes so very great, that Laennec conceived it impossible to account for it without admitting that the blood in such cases experiences a sudden dilatation. This speculation, however, as well as other theories respecting the state of the blood and its capillary vessels in hemorrhage, will be with more propriety discussed in the general article on that subject___See Hemorrhage. The occasional causes of pulmonary apoplexy are, in general, the same as those of hemorrhage from the bronchia. (See Haemoptysis.) It is to be remarked, however, that the spitting of blood which accompanies the formation of tubercles, is most frequently of the latter species ; while that which occurs in subjects affected with organic dis- ease of the heart is most commonly of the former kind : the suppression of habitual discharges, such as the menses, hemorrhoids, or epistaxis, may give occasion to both kinds indifferently. Plethora— the sudden or long-continued impression of exces- sive heat or cold, ought also to be mentioned among the occasional causes of this, as of many other diseases of a very different kind ; but in most instances such causes would not of them- selves have been sufficient to produce the disorder, without some peculiarity of constitution in the individuals. (Laennec, op. cit.) Of all these, organic disease of the heart is de- cidedly the most common. Of twenty-two cases of pulmonary apoplexy that we have examined after death, fifteen, or rather more than two-thirds of the whole, occurred in individuals labouring under heart disease ; in two instances only was the pulmonary apoplexy connected with tubercles in the lungs; in one individual the disease was caused by external injury ; in four cases we were unable to trace the hemorrhage to any local im- pediment to the circulation, or to any organic dis- ease either of the heart or lungs. Andral like- wise states, as the result of his experience, that organic disease of the heart is decidedly the most common cause of pulmonary apoplexy : (op. cit.) Cruveilhier relates two cases of pulmonary apo plexy, (Diet, de Medecine, &c.,) both of which were connected with organic disease of the heart. Of two cases recorded by Bouillaud in the Ar- chives Geneiales, one was connected with disease of the heart, the other with hepatization of the lung. Mr. Burns, in his work on Diseases of the Heart, has also noticed the frequent connexion between these diseases. «The pulmonic vessels," says he, (page 53,) " by the congestion and con- tinued vis-a-tergo, are ruptured, blood is forced into the air-cells, or, if urged still further, all the cellular structure of the lungs is crammed with blood : these organs cut like liver, and sink when put into water." Bertin, likewise, in his « JVaiti des Maladies du Cceur," particularly notices the influence of certain diseases of the heart in pro- ducing pulmonary apoplexy. According to this author, hypertrophy of the right ventricle has the same tendency to produce apoplexy of the lung, that hypertrophy of the left has to cause apoplexy of the brain, and by the same mechanism ; for as the brain directly receives the shock of the column of blood which is propelled by the aorta through the left ventricle, so the lungs receive directly the shock of blood which is propelled through the pul- monary artery by the right ventricle. According- ly, when the parietes of the right ventricle acquire an increased volume and proportionate increase of energy in their contractions, the blood is pro- pelled through the pulmonary vessels with such an increased degree of force as is sometimes suffi- cient to over-distend and rupture their parietes. The hemorrhage produced in this way he consid- ers to be of an active character, and essentially different from the passive hemorrhage which re- sults from the over-distension and rupture of the pulmonary capillaries, arising from the mechanical congestion of the lung caused by narrowing of the left auriculo-ventricular orifice. Of all dis- eases of the heart, these have the strongest ten- dency to produce attacks of pulmonary apoplexy, in consequence of the direct influence they exert over the pulmonary circulation ; but the same effect may likewise be produced by any disease of this organ which obstructs the free transmission of the blood. We have seen two cases of pul- monary apoplexy connected with hypertrophy of the left and passive dilatation of the right ventricle. In a great majority of cases the occurrence of pulmonary apoplexy may no doubt be traced to the agency of some of the causes just enumerat- ed, and may therefore be considered as a second- ary or symptomatic affection. But there are like- wise cases of this disease, in which the cause of the determination of blood to the lungs, and its escape from the capillary vessels, is not preceded by any marked derangement in the pulmonary circulation or other premonitory symptom, and must therefore, in the present state of our know- ledge, be regarded as a primary or idiopathic dis- ease, though in all probability it is only the mani- festation of some more general or constitutional derangement, particularly in those cases where apoplectic extravasations are formed in several organs at the same moment, as in the head, liver, and lungs, (Andral,) and in the case alluded to by Laennec, where he found large extravasations of blood in the cellular membrane of every limb, of the trunk, and of the greater number of the abdominal viscera. How far it may, in such cases, depend on a morbid alteration of the fluids, or on some disease of the nervous or vascular system, it is not our province at present to inquire, as these considerations will find their place in the general article on hemorrhage. Certain, however, it is, that many cases of pulmonary apoplexy oc- cur, which cannot be referred to any of the occa- sional causes enumerated by authors : indeed, the greater number of these overwhelming apoplexies, apoplexies foudroyantes of the French, are of this class. Of the six cases of apoplexy proving suddenly fatal, recorded in this article, three were in the enjoyment of perfect health up to the mo- ment of the apoplectic seizure ; a fourth, described as occurring in a robust man in the prime of life, had occasionally suffered from attacks of bron- chitis and constipation ; a fifth was in an advanced stage of typhus fever ; and in one case only could the hemorrhage "be referred to any organic disease of the thoracic viscera. 160 APOPLEXY, (PULMONARY) The diagnosis of pulmonary apoplexy is, in many cases, a matter of considerable difficulty. When the patient dies suddenly without haemopty- sis, as in cases No. 1 and 2 already recorded, it will often be impossible to determine, except by inspection, whether death was caused by cerebral or pulmonary apoplexy, or by rupture of the heart: and even in those cases where the fatal attack is accompanied with haemoptysis, the phy- sician will sometimes find considerable difficulty in ascertaining the source of the hemorrhage, as the bursting of an aneurismal sac into the bron- chia may produce effects precisely similar. In the more common and less violent forms of the dis- ease, in which an accurate diagnosis is of much more practical importance, the symptoms most pathognomonic, as enumerated by Laennec, are, violent sense of oppression in the chest; great difficulty of breathing ; cough, accompanied with irritation of the larynx, and sometimes by very acute pain of the chest; expectoration of bright and frothy, or black and clotted blood, quite pure, or mixed with salivaor mucus ; frequent full pulse, with a particular kind of vibration even when soft or weak, as it frequently is after a day or two. There is rarely any positive fever, and the heat of the skin continues natural, or nearly so ; frequent- ly the heart and arteries yield the bellows-sound to a very marked degree. Of all these symptoms the spitting of blood is the most constant and most severe, and returns by fits, accompanied with cough, oppression, anxiety, intense redness or ex- treme paleness of the face, and coldness of the extremities. When the hemorrhage is very great it comes on sometimes with a very moderate de- gree of cough, accompanied by a convulsive ele- vation of the diaphragm, like that which takes place in vomiting. (Op. cit) But of all this assemblage of symptoms, there is not one, not even the haemoptysis, which is con- stantly present; and they may all occur conjoint- ly without necessarily inferring the existence of pulmonary apoplexy. Haemoptysis is decidedly the most constant, and when very copious, the least equivocal symptom ; but there are abundant instances of pulmonary apoplexy occurring and even proving fatal with only slight haemoptysis, or even without any expectoration of blood, and likewise of profuse haemoptysis without any apo- plectic extravasation. Laennec observes that the slighter cases of haemoptysis depend upon a sim- ple exhalation from the bronchia, but that those cases of violent and extreme hemorrhage which often resist all medical treatment, almost invari- ably proceed from the vesicular structure of the lung. This distinction will be found generally correct, but still the quantity of the haemoptysis cannot be taken as a certain index of the seat of the disease; for the same author observes that, when the haemoptoic engorgement is limited to the extent of one or two square inches, the affec- tion may be latent and unaccompanied with any spitting of blood. We have seen four cases of this kind in which no blood had been expectorated during life, and it was only on dissection that the existence of haemoptoic engorgement was dis- covered. Andral has likewise seen several cases of pulmonary apoplexy, in whichithe quantity of blood expectorated did not exceed a table-spoon full at a time ; and in the more aggravated forms of the disease, death is • occasionally produced before a single drop of blood has been expecto- rated, as has been already proved by several ex- amples cited in a preceding part of this article. On the other hand, the most profuse haemoptysis may take place from the bursting of an aneuris- mal sac, from the rupture of a large vessel in a tuberculous abscess, or by simple exhalation from the mucous membrane of the bronchia. The quantity of blood expectorated can therefore only afford presumptive evidence of pulmonary apo- plexy ; in order to ascertain positively its exist- ence, we must have recourse to the signs furnish- ed by auscultation and percussion. These signs are dulness of sound in that part of the chest which corresponds with the seat of the disease, and the total absence of all respiratory murmur in the same circumscribed space, together with a crepitating rale around this space ; this rale, which here indicates a slight infiltration of blood, is al- ways found at the commencement of the disease, but is frequently wanting in the latter stages. When these signs co-exist with pulmonary he- morrhage, we may be assured that the seat of the hemorrhage is in the substance of the lung, and not simply in the bronchia. Besides these, which may be considered as the pathognomonic signs of pulmonary apoplexy, there is likewise, especially at the root of the lungs where the larger bronchia are situated, a mucous rale with bubbles, which seem to be large and thin, and formed by a matter more liquid than mucus; they also burst more frequently, and with a peculiarity of sound which cannot be mistaken. As the most common seat of this disease is in the central parts of the lower lobe, or towards the middle and posterior part of the lungs, it is consequently on the posterior and inferior part of the chest, that we ought to search for them with the stethoscope. (Laennec, op. cit.) The rationale of these signs is sufficiently obvious ; the dulness of sound and extinction of the respiratory murmur are caused by the san- guineous infiltration of the spongy texture of the part preventing the ingress of air, and converting its porous texture into a dense solid substance. The crepitating rale in the immediate vicinity of the haemoptoic engorgement in all probability arises from the bursting of the air-bubbles as they pass through the uncoagulated blood contained in the adjoining air-cells, as the bubbling or mucous rale results from the bursting of the larger bullae in the bronchia. If these physical signs could uniformly be de- tected in every case of the disease, the diagnosis of pulmonary apoplexy would be sufficiently sim- ple ; for the haemoptysis and general history of the case would serve to distinguish it from any of those diseases which exhibit the same stethoscopic phenomena, such as lobular pneumonia or clus- tered tubercles. It is evident, however, that nei- ther the dulness of sound nor the absence of respiratory murmur can be detected when the haemoptoic engorgement is of small extent, espe- cially if situated, as it often is, in a central part of the lung, or in that portion of the organ which rests upon the diaphragm; for the healthy pul- monary tissue interposed between the seat of the APOPLEXY, (PULMONARY) 161 disease and the parietes of the chest, must effec- tually mark the morbid sounds. For this reason the stethoscope rarely affords any positive infor- mation in those cases of pulmonary apoplexy, where the haemoptoic engorgement is confined to a few isolated spots, and even in more extensive cases of haemoptysis it too often fails to point out the precise source of the hemorrhage. In several cases of violent and copious haemoptysis, when, from the extreme state of dyspnoea and great con- stitutional disturbance, we had every reason to suspect the existence of an haemoptoic engorge- ment, we have found the sound on percussion not perceptibly altered, and have been unable to detect any other stethoscopic evidence of the disease than a loud mucous rale, which only served to indicate the presence of blood in the bronchia, but afforded no information as to the source from whence it came. The same difficulty of deter- mining in certain cases whether haemoptysis pro- ceeds from bronchial hemorrhage or from pulmo- nary apoplexy, has likewise been experienced by many other persons well versed in the use of the stethoscope. M. Cruveilhier even goes so far as to say that no information is to be obtained from auscultation in such a case — " Quant a I'auscul- tation et a la percussion elles ne m'ont rien ap- pris." (Dictionnaire de Mtdecine, $c.) In this opinion, however, we can by no means coincide ; for by the aid of the physical signs laid down by M. Laennec, we have been enabled, in several instances, to ascertain with precision the nature and extent of the haemoptoic engorgement The danger to be apprehended from pulmonary apoplexy, must, as in other forms of haemoptysis, depend in a great measure on the cause of the hemorrhage, the quantity of blood lost, and the previous state of the patient's health. (See Haemoptysis.) When the hemorrhage supervenes during the course of an organic affection of the thoracic viscera, such as disease of the heart, or the de- velopement of tubercles in the lungs, the nature of that affection must of course be taken into consideration in forming our estimate of the pro- bable result: in like manner, when it occurs as a vicarious discharge, or as the effect of violent exertion, general plethora, or any other appre- ciable cause, the prognosis must depend materially on the nature of such cause, and the power we possess of removing or controlling it, so that it shall not again produce a repetition of the he- morrhage. But, in all cases of pulmonary apoplexy, the prognosis should, cxteris paribus, be more guard- ed than in those forms of haemoptysis, where the hemorrhage proceeds from the bronchia, and the blood is removed from the lungs as fast as it is effused ; whereas in pulmonary apoplexy, the blood accumulates in the parenchymatous sub- stance of the lung, and often renders a consider- able extent of that essential organ unfitted for the purpose of respiration : besidrs which, the blood effused into the air-cells may in some degree be regarded as a foreign body capable of producing various morbid alterations. Laennec states that resolution of the haemop- toic engorgement takes place with considerable Vol. I. —21 °* facility, whatever may be the severity of the dis- ease. In those instances where he had an oppor- tunity of tracing the progress of this resolution by dissection, he found that the indurated parts passed successively from dark red to brown or pale red, and that, in proportion as the colour faded, the parts lost their granular texture and density. When the resolution is complete, it leaves no trace of the disease in the pulmonary substance : (op. cit) This favourable termination of the disease may be known during life, by the progressive improvement which takes place in the patient's respiration and general health, by the sound or percussion becoming gradually clearer as the resolution advances, and by the crepitating rale becoming audible over the surface of the haemoptoic engorgement: it is not, however, so constantly audible in this disease as during the resolution of pneumonia. In a few cases of pul- monary apoplexy where we had an opportunity of watching the progress of the resolution, we were unable to detect either the crepitating or sub-crepitating rale, but the sound on percus- sion became gradually clearer, and the respiration, which was at first extremely faint, slowly returned to its natural state. M. Boillaud records a case— a solitary instance we believe—in which a clot of pulmonary apoplexy was found surrounded by a well organized cyst, precisely similar to those which are occasionally developed round apoplectic extravasations in the brain, and which, like them, was probably destined to become an agent of ab- sorption. (Observations pour servir a I'histoire d'apoplexie pulmonaire par M. J. Bouillaud.) Besides these, which may be regarded as the favourable terminations of haemoptoic engorge- ment others of a less favourable nature have also been described by pathologists. Thus, according to Andral, " It sometimes happens that the blood extravasated into the lung, instead of being ab- sorbed, has a tendency to acquire a right of settle- ment there by becoming organized, and thus ren- dered capable of performing the different acts of nutrition and secretion ;" in this state it may be- come a nidus for the developement of different morbid productions, such as tubercle, melanosis, pus, &c. We are disposed to think, however, that the developement of tubercles can seldom be traced to this source, as in eighty-six cases of phthisis, of the dissections of which we have kept pretty accurate notes, we only find mention made of an haemoptoic engorgement having been found in two individuals ; and even in these instances it is just as probable that the tubercles may have caused the apoplectic extravasations, or that both may have been effects produced by a common cause. Laennec likewise observes, (op. cit.) that the haemoptysis which precedes or accompanies the symptoms of confirmed consumption, arises much more frequently from bronchial hemorrhage than from pulmonary apoplexy ; and the accuracy of this observation has been confirmed by Louis and Andral. The suppuration of the apoplectic mass, and its evacuation by the bronchia, have been enumerated by M. Cruveilhier (op. cit.) among the termina- tions of this disease. As, however, this opinion is not supported by observation, and is directly contradicted by Broussais (Phlegmasies Chro- 162 APOPLEXY, (PULMONARY) niques), we may conclude that its occurrence is exceedingly rare, if indeed it ever takes place. Lastly, pulmonary apoplexy has been observed to occur as a precursory symptom of gangrene, and may, we conceive, in some cases contribute to produce it In one instance particularly we were enabled to follow the different stages of the dis- ease from the formation of an extensive haemoptoic engorgement to its conversion into a large gan- grenous abscess. The rationale of this transition may, we con- ceive, be explained thus.- in the haemoptoic en- gorgement the circulation through the indurated mass is completely obstructed by the solidification of the part, and by the vessels leading to it being plugged up with coagula of fibrine. This plug- ging up of the vessels has been noticed by Laen- nec, and more particularly by Bouillaud, (op. cit) and we have repeatedly ascertained the fact on dissection. Now if we compare the condition of the part thus circumstanced with the pathology of gangrene as laid down by the most recent and approved authorities on the subject, we shall find it placed under precisely the most favourable cir- cumstances for passing into gangrene, or, as the disease has been more appropriately designated by Dr. Low, putrefactive disorganization of the lung. " I have already shown," says M. Andral, (Treatise on Pathological Anatomy, translated by Dr. Townsend, page 513,) "that gangrene is not necessarily preceded by any violent degree of irritation, but may be produced by any cause which retains the blood in the capillaries of the part, especially if by such stagnation the arrival of fresh blood by the arteries is prevented. In some persons the slightest stagnation of the blood has a remarkable tendency to be followed by gan- grene of the part: this disposition to gangrene, which in these persons is constitutional, may be produced in others by a variety of causes ; and in Cruveilhier's folio work on morbid anatomy we read the following account of the pathology of gangrene: — "Gangrene is a morbid condition which may occur primitively in any tissue of the body, or consecutively in any organic disease, such as inflammation, cancer, tubercle, &c. In fact it always supervenes whenever the course of the blood is intercepted either by a mechanical obsta- cle, or by the obstruction of the principal and collateral arteries or veins." (Anatomie Patho- logique du corps humain, 3me livraison.) The consideration of this subject will be more fully resumed in the article gangrene : we have only alluded to it at present, because, if we admit the possibility of gangrene supervening on a haemoptoic engorgement, our prognosis must al- ways contemplate the possibility of such an event, especially when the engorgement is extensive, and occurs in those conditions of the constitution which have been observed to be most favourable to the formation of gangrene. The treatment of this disease must of course be regulated, in a great degree, by the age, constitu- tion of the patient, and the quantity of blood already lost; the cause of the hemorrhage must likewise be taken into consideration, in order that the treatment may be adapted to the nature of the disease, and not to the name it bears. The mea- sures pursued for the cure of pulmonary apoplexy when connected with purpura, or scurvy, must differ very materially from those which are em- ployed when it proceeds from plethora, or hyper- trophy of the heart. As a general rule, however, it may be laid down, that the principal indications to be fulfilled in the treatment of this disease, are to arrest the further progress of the hemorrhage by the prompt employ- ment of such measures as are best calculated to reduce plethora, moderate the action of the heart and arteries, and change the determination of blood, and in the next place, to prevent a recur- rence of the hemorrhage by removing, or where that is impracticable, controlling those causes which may in any way tend to reproduce it, as, by re-establishing any habitual discharges, whose suppression may have led to the vicarious hemor- rha «\ or by removing, or at least palliating any organic disease, or constitutional disturbance with which the hemorrhage might have been originally connected. The diseases both local and constitu- tional with which pulmonary apoplexy is usually connected have been already enumerated among the causes of this affection ; it is therefore unne- cessary to repeat them here: the treatment adapted to each will be detailed in their respective articles. As we shall have occasion, when treating of haemoptysis, to enter fully into the consideration of the different remedial agents that have been found most efficacious in suppressing pulmonary hemorrhage, we shall, in order to avoid repetition, refer the reader to the article on that subject, only remarking that, as the hemorrhage is in general much more profuse in this variety of the disease than in bronchial hemorrhage, and as the accumu- lation of blood in the parenchymatous structure of the lung is always attended with considerable danger and distress, and the resolution of the in- durated part at best a slow and uncertain process, our treatment should be proportionally prompt and decisive. With this view it is advisable to open a vein largely, and draw blood freely, at the very onset of the disease. The application of leeches has generally been found a very inefficient substi- tute for the free use of the lancet. Dr. James Clark states that, in plethoric individuals threat- ened with apoplexy or haemoptysis, the applica- tion of leeches frequently decides the very occur- rence of the disease it was intended to prevent: (note to Dr. Forbcs's translation of Laennec.) A very small bleeding from a vein may also, aa Laennec observes, produce the same effect: ac- cording to this author, one bleeding of twenty or twenty-four ounces on the first or second day will have more effect in checking the hemorrhage than several pounds taken away in the course of a fort- night. It is even beneficial in general to induce partial syncope by means of the first bleeding; and he adds that in cases of this kind the fear of ex- hausting the patient's strength is without grounds, since we know that the most copious venesection falls short of the loss of blood sustained from pul- monary hemorrhage in young and robust subjects even in the course of a few minutes; while the debilitating effect of the hemorrhage is infinitely greater than the loss of blood produced by the lancet. Should the hemorrhage continue after the pulse has become small and weak, and the APOPLEXY, (PULMOI strength much reduced, it will not be prudent to I employ further venesection, but to have recourse ] to derivatives, among which purgatives are un- I questionably the most efficacious. A drastic ene- ma or cathartic frequently checks the hemorrhage, and even the hemorrhagic molimen, especially if they are productive of faintness. Nauseating doses of tartar emetic have likewise been found beneficial in controlling the circulation. The acetate of lead, too, has been highly extolled in this disease for its sedative and styptic qualities. Dr. Mackintosh states that he has seen it, when administered in full doses, act in the most wonder- ful manner in suppressing even those hemorrhages which were afterwards proved by dissection to have proceeded from a ruptured blood-vessel in the lung, (Mackintosh's Practice of Physic,-) and he strongly recommends it in those cases of pulmo- nary apoplexy where the patient has lost too much blood before we are called, or where the hemor- rhage continues after sufficient bleeding. Prussic acid will also be found useful in controlling the inordinate action of the heart and arteries, which not unfrequently subsists after much blood has been lost, and likewise in allaying the teazing cough and irritation in the throat, which are some- times very troublesome in this disease. We have likewise found digitalis useful in this way, parti- cularly in those cases where the pulmonary affec- tion was connected with diseases of the heart. It is scarcely necessary to add that the antiphlogistic regimen must be strictly enforced, and that rest, silence, and cool air are indispensable. R. Townsend. [Appendix vermiformis c,eci, IN- FLAMMATION OF THE. See ENTERITIS.] ARTERITIS. Much difference of opinion has subsisted amongst authors respecting inflamma- tion as occurring in the interior of the heart and arteries. Some, amongst whom Laennec holds the most distinguished place, have thought it extremely rare ; others have attributed to it nearly all the morbid appearances and changes that are found in those parts. It will be convenient to consider the subject under the separate heads of acute and of chronic arteritis, ranging under each its proper anatomical characters, and the morbid alterations that appear to belong to it Acute arteritis. The anatomical characters of acute arteritis are, redness of the internal membrane of the heart and arteries, an effusion of plastic, pseudo-mem- branous lymph on its surface, and thickening and ulceration of its substance. Each of these charac- ters will be considered in succession. Redness of the internal membrane of the heart and arteries. — This is sometimes inflammatory, and sometimes not The redness not inflamma- tory often appears in the aorta, the pulmonary artery, and the heart, and is a uniform intense colour, as if stained by the blood. Corvisart avows that he cannot give a satisfactory account of its nature and cause. (Corvisart, p. 36.) P. Frank regarded it as an inflammation of the arteries, which, according to him, occasions a peculiar and almost always fatal fever. (De Curand. Homin. Morbis, torn. ii. p. 173.) Bertin and Bouillaud have considered it, whatever was its shade, as the URY)- ARTERITIS. 163 result of inflammation. (Traite, &c. p. 55.) Laennec entertains an opposite opinion, and de- monstrates satisfactorily that the redness in ques- tion, when not accompanied by other anatomical characters of inflammation, is the result of san- guineous imbibition. This opinion has been con- firmed by the discoveries of Dutrochet* As it is necessary that the reader be able to judge for himself, we shall give some account of this redness, adhering to the description of Laen- nec, which we have verified by repeated experi- ments and dissections. The redness is sometimes scariet, and sometimes brown or violet. The scarlet redness of the inte- rior of the arteries is often confined to the internal membrane exclusively; and, when that mem- brane is removed by scraping with the scalpel, the fibrous coat is found underneath as pale as in its natural state. But in other cases the Tedness penetrates moTe or less deeply into the fibrous coat, and sometimes reaches, in parts, even the cellular or external tunic. The redness of the internal coat is a perfectly uniform tint, similar to that which would be presented by a piece of parchment painted red. No trace of injected capillaries can be distinguished in it, but the tint is sometimes deeper in one part than another. Sometimes it diminishes insensibly from the ori- gin of the aorta to the place where the redness ceases ; but very often it terminates suddenly, and by forming abrupt borders of an irregular shape. Sometimes, in the midst of an intensely red por- tion, is found an accurately circumscribed patch of white, which produces precisely the effect that is occasioned by an impression of the finger on a part of the skin affected with phlegmon or ery- sipelas. When the aorta contains very little blood, the redness only exists in the tract in con- tact with it, and forms a sort of ribbon. The ori- gin and arch of the aorta are the parts of that artery which are the most frequently found thus reddened. Sometimes nearly all the arteries pre- sent the stain. The aortic and mitral valves then participate in it, and appear as if they had been plunged in a red dye. Though the red is scarlet in the arteries, it is deeper on the valves, approxi- mating slightly to purple or violet. When the pulmonary artery is reddened, its valves and the tricuspid are also very commonly stained in the same way. The stain of the right cavities and vessels of the heart is always of a deeper and browner hue than that of the left; a circumstance dependent, in all probability, on the darker colour of the venous blood. The internal membrane of the ventricles and auricles sometimes does not present any sensible change of colour, even when the valves are the most deeply reddened. Still, it is not rare for the internal membrane of the auricles to participate in the redness, and in this case its tint resembles that of the valves. More rarely, the surface of the ventricles also presents a similar redness, but ordinarily it is browner or more violet. Sometimes the internal surfaces of the ventricles and auricles are the only parts red- dened ; but this never-occurs except when the heart is gorged of blood, and the arteries contain scarcely any. The redness above described is not * Dutrochet, Nouvelles Recherches sur l'Endosmose et l'Exosmose. Paris, 1826. 164 ARTERITIS. accompanied with any sensible thickening or vascular injection of the stained membranes. A few hours' maceration in water suffices to make it totally disappear. Such are the characters of the scarlet redness. We next come to the brownish or violet stain. It is found equally on the aorta, the pulmonary artery, the valves, the auricles, and the ventricles. Most commonly, indeed, it is unserved in all these parts at once. It is often very unequal in inten- sity, and is always more marked on the parts of the vessels that, according to the laws of gravity, have been most in contact with the blood. It is not so commonly restricted to the lining membrane as the scarlet redness ; for the muscular substance of the auricles and ventricles, and even the fibrous tunic of the aorta and pulmonary artery participate in the dye ; at least, in some points, and to a cer- tain depth. Such is Laenuec's account of redness of the in- ternal membrane. But redness, he contends with great justice, is not sufficient to characterise in- flammation, particularly when it is not accompa- nied by thickening or vascular injection of the reddened parts. Moreover, the exact circumscrip- tion of the redness in some cases, and its abrupt termination by geometrical though irregular lines —an appearance never seen in inflammation of serous membranes, though it is occasionally and to a slight degree in that of mucous*—banish the idea of inflammation, and rather convey that of a stain by a coloured liquid which had run irregu- larly on the reddened membrane, or which, on ac- count of its deficient quantity, had not been able to touch every part. Again, the circumstances under which the redness is usually found, coun- tenance the idea of its being a stain rather than from inflammation. Laennec has found the scarlet red to occur after a somewhat protracted agony in subjects still vigo- rous, but yet cachectic, in consequence of disease of the heart or otherwise. The blood in these cases was never very firmly coagulated, and the body most frequently presented some signs of de- composition. The brownish or violet red he found in those subjects especially who had died of con- tinued typhoid fevers, of emphysema of the lungs, or of disease of the heart. Almost all had expe- rienced a long and suffocative agony ; in all, the blood was very liquid and evidently altered, and signs of premature decomposition existed in the bodies. We have found it also very constantly in cachectic subjects affected with passive hemorrhage from the gums, from ulcers, &c. as in scurvy. It is moreover, in summer particularly, and in sub- jects that are opened more than twenty-four hours after death, that the dark discoloration is most frequently met with. Both varieties of red- ness, and particularly the brownish or violet, are accompanied with a greater or less degree of soft- ening of the heart, and with an increased humidity of the arterial walls. In most instances these states are evidently the effects of a commencement of putrefaction. Laennec has strong doubts whe- ther the scarlet redness e*ver produces symptoms sufficiently severe and constant to render it capa- ble of being recognised. He has found it in sub- * We have seen it in the trachea in variola. See also Bretonneau on Diphtherite. jects who had died of widely different complaints, and he was never able to predict it by any con- stant sign. The cases which Bertin and Bouillaud have adduced in substantiation of their opinion, that the redness in question is of an inflammatory na- ture, are strikingly corroborative of the views of Laennec. For, of twenty-four cases, eleven are typhoid fever, or other affections in which there was a manifest alteration of the liquids, and pre- mature putrefaction. The thirteen other cases consist almost entirely of consumptive patients; and the writers observe, in general terms, that the redness appeared to coincide with a remarkable fluid state of the blood. It must further be re- marked, that most of their examinations were made in summer, and more than thirty hours after death. In order to ascertain experimentally whether blood could occasion a stain, Laennec enclosed a quantity in a sound and recent aorta, and placed the preparation in the stomach of the subject, in order to preserve it from drying, and to put it under the same circumstances of decomposition as the rest of the body. In twenty-four hours it pre- sented a perfect specimen of the scarlet dye, which was not weakened by reiterated washing. Ac- cording to his experiments, blood too firmly co- agulated causes imbibition feebly and slowly. Blood half coagulated, and particularly the blood still slightly florid, which may be pressed out of the lungs, produces the scarlet redness. Very liquid blood, and particularly that with a serous intermixture, produces a violet colour of greater or less depth. If the artery be only partly filled, the dye occupies those parts alone which are in contact with the blood, and forms a ribbon. If the walls of the artery are firm and elastic, the dye requires a long time (seventy or eighty hours) for its formation, and is never very deep ; but if, on the contrary, the walls are soft, supple, and charged with humidity, the dye promptly pene- trates through the whole thickness. Warm wea- ther and the rapid progress of putrefaction are favourable to the imbibition. Boerhaave and Morgagni attributed the red colour to the stagnation of blood which takes place during the agony in diseases accompanied with great oppression ; and Hodgson maintains that arterial redness, such as that above described, does not arise from acute inflammation, as it is not accompanied by any other anatomical charac- ters of inflammation. When occurring in the vicinity of coagula, it is, in his opinion, an effect of imbibition after death. It is impossible not to conclude from all the evidence now adduced, that redness of the inter- nal membranes of the heart and arteries cannot alone prove inflammation, and that it is a pheno- menon taking place during the agony, or after death, whenever it is found in conjunction with the following circumstances : namely, a prolonged and suffocative agony ; manifest alteration of the blood ; and a somewhat advanced decomposition of the body. Such is the redness of the internal membrane of the heart and arteries which is not inflamma- tory : we now proceed to that which is. The co- lour of the latter may be the same ; for the mem- ARTERITIS. 165 brane, though inflamed, is still liable to imbibition. In the absence of imbibition, the redness is fainter, less shining, more equably diffused, and less cha- racterised by streaks, patches, isolated unstained spots, and abrupt edges. Effusion of lymph on the internal mem- brane, WITH THICKENING OF ITS SUB- STANCE. Whether the redness be due to vascularity alone, or to this conjoined with imbibition, its in- flammatory nature is known by the presence of certain other anatomical characters of inflamma- tion. These are, thickening, swelling, and puffi- ness of the inner membrane; and effusion of lymph on either its free or adherent surface ; and a preternatural vascularity, with softening and thickening, of the middle arterial coat. Each of the coats may be separated from the other with much greater facility than natural by scraping with the nail or scalpel. The internal and middle coats, in short, present all the phenomena of the adhesive inflammation, as it occurs in other mem- branes. It is by this inflammation that, if an artery be wounded or divided; if it be compressed by a ligature or tumour; or if it be simply irritated by ulceration of the surrounding parts or a pul- monary vomica, and effusion of lymph takes place into the cavity of the vessel, and into the cellular tissue, both investing it externally, and connecting its several coats, by which its caliber is obliterated and hemorrhage prevented. Although obliteration never takes place in the aorta from inflammation alone, this vessel some- times exhibits the vestiges of acute inflammation more palpably than smaller arteries. Thus, in a case seen by Dr. Farre, the internal coat of the aorta was of a deep red colour, and a considerable effusion of lymph had taken place into its cavity. The lymph was very intimately connected with the internal coat (Hodgson on the Arteries, p. 5, plate 1, fig. 5.) Similar instances have been seen by Hodgson, (Ibid. p. 6,) Bertin, (Case ii. p. 7,) and apparently by Portal, (Cours d'anato- mie medicale, torn iii. p. 127,) and Morgagni and Boerhaave, (Morgagni, Epist. xxvi. Art 36 ;) and lymph has been found effused within the auricles and on the valves by Baillie, (Morbid Anat Edit. 5, p. 85,) Laennec, (De I'Auscult torn. iii. p. 127,) Burns, (On Diseases of the Heart ch. ix.) We have met with it both in the heart and aorta. Effusions of lymph within the heart and great arteries, however, are very seldom witnessed ; and hence it is, that Laennec thinks inflammation of the internal membrane of those parts extremely rare. (Dc I'Auscult torn. ii. p. 598.) But the presence or absence of lymph is not sufficient to determine whether inflammation exist or not; for, in many instances, the lymph, when first effused, is washed away by the force of a circulation so powerful as that in the heart and aorta. Laennec considers a layer found on the internal membrane of the heart or gTeat vessels, to be the only incon- testable sign of inflammation of that membrane, and, with ulceration, the only certain one, (Ibid. p. 607 :) for he doubts whether redness of the membrane, even when conjoined with thickening, swelling, puffiness, and an unusual development of 6mall vessels in the middle tunic, would satis- factorily prove inflammation in a subject conside- rably infiltrated, and whose tissues are very hu- mid. (Ibid.) This is a point which can only be determined by the judgment of the physician in individual cases. We recently met with a case precisely such as Laennec describes, and, at the first glance, it struck us and two eminent medical friends as being inflammatory ; but a brief inspec- tion proved the reverse. It is necessary, however, to be alive to this source of fallacy. Kreysig, Hodgson, and Bertin and Bouillaud are of opin- ion that lymph effused by inflammation is the source of fungous or warty vegetations of the valves. Laennec rejects this opinion, and attri- butes the vegetation to sanguineous concretions which adhere to the internal membrane, and be- come organized. He does not deny, however, that an inflammatory false membrane may be- come the nucleus of these concretions. This sub- ject will be more fully considered under the head of vegetations. Effusions of lymph are, in some instances, the result of chronic inflammations ; for they are found in the vicinity of ossifications of arteries and other morbid alterations of a chronic nature. We have seen an ossified common iliac obliterated by a plug of lymph. Hodgson has witnessed nearly the same ; and Dr. Goodison found the aorta itself obliterated by lymph, at a part where its whole circumference was converted into a bony cylinder. This lymph must have been secreted gradually ; as the force of the aortic circulation would have washed away any soft and copious recent effusion. It is probable that the obliteration of arteries in the neighbourhood of vomicae and other ulcera- tions, and of tumours, is also occasioned by chro- nic inflammation. Ulceration of the internal membrane___Ulcera- tion of the internal membrane sometimes takes place from acute inflammation, without any lesion of the subjacent tissues. This, however, is rare ; for, in general, the ulceration is a consequence of some previous chronic degeneration of the coats of the vessel, and is, in the first instance, rather a solution of continuity than an ulceration. Such is the case when it is occasioned by the detach- ment of calcareous incrustations, or by the depo- sition of atheromatous or other matter underneath the internal membrane. Ulcers from these causes are not uncommon, and though they do not, strictly, come under the head of acute arteritis, they may be conveniently considered in this situa- tion. They vary in size from a mustard-seed to a pea or bean, have more or less thick and ragged edges, and are sometimes so deep as to reach, and even to perforate, the external or cellular tunic. Laennec describes the formation of these ulcers from calcareous incrustations in the following manner : « When a calcareous incrustation," says he, " is detached from the aorta, the species of sinus left by it is filled up by fibrine, which be- comes, by decomposition, of the consistence of friable paste, and is often intermixed with phos- phate of" lime." This paste, when soft and pulpy, has been denominated melicere, or atheroma. Not unfrequently, the borders of the lesion are reddened for a little distance; and this he attributes to imbibition of blood, (rendered more easy in an altered structure,) rather than to chronic inflam- mation, which he thimks is not proved either by 166 ARTERITIS, the presence of pus, or of any symptoms, local or general, that can be referred to it. These lesions, therefore, he regards as being, in the first instance, merely solutions of continuity from an entirely mechanical cause; and not ulcers, occasioned by inflammation. He does not deny, however, that the oldest and most extensive of them sometimes become ulcers ; for the internal membrane at the borders of the lesions is slightly tumid and red, and the surface of the fibrous tunic at their base is manifestly altered. But he contends that the inflammatory action which gives them the charac- ter of ulcers, is the effect, not the cause, of the solution of continuity. Solutions of continuity occasioned by the detachment of calcareous in- crustations, are among the most frequent causes of consecutive false aneurisms. Small pustules filled with pus sometimes, though rarely, present themselves under the internal mem- brane of the aorta, and burst into its cavity. It is probable that they form the genuine or primitive ulcers of that vessel.—those which are the most frequent cause of its perforation. They sometimes throw out curdy, and even calcareous matter. Laennec thinks that these pustules are occasioned by inflammation; not of the internal, but of the middle arterial tunic, or of the fine cellular tissue which unites the middle to the internal tunic; and he is of this opinion, because, in inflammation of all membranes, as the peritoneum, the pleura, the mucous membrane lining the bronchia, &c. pus forms on their free, and not on their adherent sur- face. Therefore, as this secretion is found on the adherent surface of the inner arterial membrane, he infers that the inflammation occasioning the pustule is seated, not in that membrane, but in the subjacent tissues. Pus is scarcely ever found on ulcers of the heart and arteries, because it is washed away as soon as secreted. For the same reason, it is never found on the internal surface of arteries that are inflamed without being ulcerated, though analogy leads us to believe that, under these circumstances, it is secreted. Ulcerations are extremely rare in the cavities of the heart. We recently met with an instance, originating in a curdy deposition under the lining membrane. We have never seen or heard of a case in which inflammation, when confined to the interior of an artery, terminated in gangrene. Arteries, however, are frequently involved in the when so affected, is thickened, softened, and of a deep dirty red colour. These appearances are not uniformly diffused, but are more marked in the vicinity of calcareous and other degenerations. Hence some have supposed that these degenera- tions were the cause of the inflammation. There can be little doubt that they tend in many in- stances to keep it up ; but it is highly probable that the degenerations themselves were originally caused by increased vascular action of a chronic nature. Whether the increased vascular action be in every case, particularly those of calcareous depositions, strictly inflammatory, we shall inquire after bringing the various degenerations under review. Meanwhile it may be remarked that the appearances in arteries presented by chronic in- flammation accompanied with morbid depositions, have been well known to authors from a very early period. The ancient physicians ascribed them to acrimonious, syphilitic, and scorbutic humours pervading the system. Some modern writers also, particularly Corvisart, Scarpa, Richerand, and Hodgson, impute them to similar causes, espe- cially to the syphilitic virus, or to the mercury used for its eradication. MoRBin ALTERATIONS IN THE COATS OF ARTE- RIES, AND ESPECIALLY OF THE AORTA. The morbid alterations in the interior of the aorta which appear to be of chronic formation, are, steatomatous, fibrous, cartilaginous, and calca- reous depositions, with a thickened, fragile, and inelastic condition of the arterial coats. The most simple of these alterations is, a loss of elasticity, generally accompanied with increased density and opacity of the coats of the artery. This state is sufficient of itself to give rise to dilatation, by a process which will be described under the head of dilatation of the aorta. Before describing the depositions, it may be premised that they originate, not in the internal coat, but either in the middle coat, or in the fine cellular tissue interposed between it and the inter- nal coat; that this coat can sometimes be peeled off from them in a perfect state, even when they are far advanced ; and that the productions them- selves are more analogous to those of a fibrous than of a serous membrane. The extent, the form, and the thickness of the productions are infinitely various : sometimes the several species exist separately, but more com- sloughing of surrounding parts; in which case i monly they are found more or less intermingled the blood generally coagulates in the vessels to a ' in the same artery. The first and most common considerable extent above the line of sphacelation, and thus prevents hemorrhages. (Hodgson, p. 17.) It remains to be noticed that arteritis is some- times of an erysipelatous nature. We allude to that which follows an injury of an artery, as by a ligature, a gun-shot wound. &c. especially if there be deep- seated disease in the muscles of the part affected. appearance is that of small, opaque, straw-coloured spots, immediately underneath the lining mem- brane, with slight inequality and corrugation of the membrane around them. At a more advanced period the depositions form considerable, slightly elevated patches, which, becoming confluent, sometimes overspread the whole surface. Some The inflammation, in these cases, sometimes runs I of these patches have much the appearance and consistence of bees'-wax, or cheese, though in general their cohesions and flexibility are greater. These are usually denominated steatomatous. Others, presenting nearly the same colour, have a fibrous or ligamentous appearance ; while others, again, are more translucent, white, and elastic- like cartilage or fibro-cartilage. All the deposi- tions described are accompanied with thickening ! and loss of elasticity of the internal coat, which along the internal coat of the artery till it reaches the heart It is a most formidable disease, rapidly producing great irritative fever, an extremely quick pulse, complete collapse, low delirium, and gene- rally death. Chronic arteritis anb the morbid alter- ations CONNECTED WITH IT. Arteries are more subject to chronic than to acute inflammation. The internal membrane, ARTERITIS. 167 becomes knotty, wrinkled, and sometimes cracked, scaly, and fimbriated. This, however, is less deci- dedly the case until earthy depositions have taken place. These generally commence in the midst of a cartilaginous or fibro-cartilaginous patch, though they are sometimes found in detached scales, and sometimes in a soft or pasty form, in the midst of cheesy, curdy, or melicerous matter. WThen they form incrustations, the shape of these is irregularly flattened; the prominences being towards the exterior rather than the interior of the artery. Their external surface sometimes presents the imprint of the circular fibres of the middle tunic. Their internal surface is sometimes smooth, and evidently covered by the membrane ; in other cases it is rough, and the membrane is more or less destroyed. Calcareous depositions occur most frequently in the ascending portion and arch of the aorta, but occasionally they per- vade the whole of the vessel, and even almost the whole of the arterial system. We saw a case in the Hotel Dieu, in which the great arteries from the heart to the ankle were converted into rigid tubes by ossification, which in parts occupied all the coats and the whole circumference of the ves- sels. In another case, at St. George's Hospital, the common iliacs were rigid ; and one of them, which was converted into a long cylinder, was obliterated by a plug of dense lymph. The arte- rial system was elsewhere more or less ossified. Both the patients died with gangrenous sores of the legs. In the arteries at the base of the brain, calcare- ous and other degenerations are remarkably fre- quent, and are a principal cause of apoplectic effu- sions. It is rare, indeed, to meet with an instance of such effusion, exclusive of those dependent on external violence, in which some disease of these arteries may not be detected; and it may be remarked in passing, that, in most instances, the disease of the artery is connected with hypertro- phy of the left ventricle ; whence it appears to be referable to over-distension, to which the cerebral arteries are more obnoxious than others, in conse- quence of their being without the cellular coat, and being ill-supported by the pulpy yielding sub- stance of the brain. We have met with several cases of epilepsy which had no other obvious cause than disease of the cerebral arteries. The arteries below the pelvic divarication of the aorta are more frequently ossified than those of the upper extremities and trunk. Calcareous concretions differ essentially from natural bone. For though some are formed by the secretion of the earthy phosphate in cartilage, even these have not the peculiar fibrous arrange- ment of bone. But in by far the greater number of cases, the earthy matter is not secreted in any cartilaginous matrix whatever, but is simply depo- sited in the form of an irregular homogeneous crust or crystallization, without any determinate arrangement, and without vitality. The propor- tion of animal matter in these is very small. Mr. Braude found 100 parts to consist of 65.5 of phosphate of lime, and 34.5 of animal matter. In some specimens we have found the quantity of animal matter considerably less. When ossification is very considerable, it is sometimes attended with induration, inelasticity, and fragility, not only of the internal, but of all the arterial coats; and this state I have seen at- tended in some cases with thickening, and in others, though less frequently, with extenuation and a horny translucency of the walls of the ves- sel. The aorta, so affected, generally undergoes dilatation, but very rarely contraction. When the depositions are partial and limited, the internal membrane in the intervals is often perfectly sound. This is especially the case in the ossifications of old people. It is remarkable that, though morbid depositions are so frequent in the aorta, they are extremely rare in the pulmonary artery. Out of upwards of a thousand cases, in which we have examined this vessel, we have never met with cal- careous depositions in its coats, and only three or four times with cartilaginous and steatomatous disease and dilatation. Causes ofmorbid depositions in the coats of Arteries. — Some authors have considered morbid depositions in the coats of arteries to be, in every case, the various metamorphoses of lymph, effused by inflammation of the acute kind and of such intensity as always to proclaim itself by ob- vious symptoms, and require antiphlogistic treat- ment. Others, again, have supposed that many, if not all, of the depositions in question, take place quite independently of inflammation of any kind. As principles of treatment of a decided nature have been founded on each of these conflicting doctrines, it is a matter, not of mere speculation, but of practical importance, to look into the sub- ject, and endeavour to ascertain the truth. Although it would be difficult to deny that acute inflammation may, in some instances, lay the foundation of morbid depositions in the coats of arteries; yet it is certain that they may and do occur independent of it; as they have been found in individuals who had never manifested any symptoms whatever of inflammation, and who had even constantly enjoyed the most perfect health. Analogical evidence derived from other membranes leads to the belief that chronic inflam- mation is, in most instances at least, the main agent concerned in the production of these depo- sitions. Thus, for example, the dura mater and the pleura are sometimes not only thickened and indurated, but converted into fibrous, cartilaginous, or bony tissue. We have seen the dura mater converted into a calcareous plate nearly as large as the hand, and overspreading one hemisphere of the brain. The preparation was shown to us by Professor Monro, and is in his museum. Mr. Hammick showed us two preparations, in his mu- seum, of calcareous plates, of about two inches in diameter, on the pleura. Changes of this kind are, by general consent, attributed to chronic in- flammation ; as they are not only found in con- junction with organized adventitious membranes and other anatomical proofs of that form of in- flammation, but are often attended with its symp- toms. It is to be presumed, therefore, that cor- responding changes taking place within an artery are referable to the same cause. That the morbid depositions in the artery should not be exactly identical with those found in other membranes is to be anticipated on principles of general anato- my ; for the effused matter, which is the basis of every accidental production, differs in aspect and 168 ARTERITIS nature according to the tissue in which it occurs. Thus, as well remarked by Bertin, the cellular tissue and parenchymatous organs secrete pus, properly so called ; thus serous membranes secrete a coagulable matter prone to transform itself into cellular or serous layers ; thus the periosteum fur- nishes another matter, which concretes, hardens, and ossifies; thus the arterial tissue, composed essentially of a fibrous membrane, exhales a liquid which hardens, condenses, and becomes convert- ed into cartilaginous patches, or calcareous scales. But admitting the agency of chronic inflam- mation as a cause of morbid alterations in arte- ries, there is reason to believe, as before stated, that some of them, particularly the calcareous, may take place independently of it; for they are found in most old people ; they sometimes occur in various detached points very remote from each other; they often consist of a simple calcareous scale, or an opaque yellow spot, without any mor- bid state of the surrounding membrane ; and such alterations almost always take place without afford- ing the slightest sign, either general or local, of their formation. Now, it is scarcely possible to conceive an inflammation which manifests no symptoms, which is restricted to isolated points often remote from each other, which leaves none of the ordinary vestiges of inflammation in the surrounding membranes, and which is the most frequent at that period of life when phlogistic ac- tion is the least prevalent We are brought, then, to inquire, what is the cause of morbid depositions when they do not appear to be referable to inflam- mation. Here it is necessary to proceed with caution, as the ground is purely speculative. Laennec, in- deed, thinks it the most simple and philosophical to acknowledge that we know not the derange- ment of the economy which produces an ossifica- tion or a cancer, but that very certainly it is not the same as that which produces pus—as inflam- mation, (De I'Auscult vol. ii. p. 684.) If we are not satisfied to remain in this circumspect uncer- tainty, we can scarcely venture farther, in the ac- tual state of our knowledge, than to suppose that morbid productions are sometimes results of a de- praved action of the vessels not identical with or not amounting to inflammation—a doctrine, in- deed, which rests on the basis of sound observa- tion, and which has been extensively received, since the accurate researches of the present cen- tury have bred a "philosophic doubt" on the tenet of the ancients, that all accidental produc- tions are the effects of inflammation. Admitting a depraved action of the vessels, it is rational to suppose that, like inflammation, it would derive its particular character from the tissue which it affects : hence that the fibrous and fibro-serous tissues of the arteries would degenerate into car- tilage, bone, &c.—the changes to which they are most prone under the influence of inflammation. But what is it that calls this depraved action into activity ? It appears to us that over-distension of the arteries by the force of the circulation is what, principally at least, produces the effect. To this opinion we are led by the following conside- rations : that arterial ossifications are the most common when the left ventricle is hypertrophous ; that (according to an observation of Boerhaave, related by Morgagni) they are found in stags long and often exercised in running, and not in those which lead a tranquil life in the parks of the great; that diseases of arteries and aneurism are more common, in the proportion of at least seven or eight to one, in men than in women, the life of the former being much more laborious and the cir- culation more liable to excitement from potation of vinous or spirituous liquors, &c; that ossifi- cations, &c, occur in those arteries more especial- ly which are most exposed to over-distension, namely, the arch of the aorta, which immediately sustains the whole brunt of the left ventricular contraction, and the arteries of the brain, which, not having the support of a cellular sheath, and being bedded in a soft puffy substance, are weaker than any others ; that they are more especially incident to the aged, in whom the arterial and all other tissues sustain a diminution of elasticity and cohesiveness in consequence of the diminished vascularity which characterises old age. Perhaps the same reason, viz., over-distension, may be as- signed for the remarkable frequency of the arterial depositions in those who have suffered much from syphilis or mercury ; for as these maladies induce a cachectic state which lessens the elasticity of all the tissues, the arterial tissue would, under these circumstances, suffer proportion ably more from the distensive pressure of the circulation. To the above catalogue we may perhaps add gout—an affection which is remarkably often attended with arterial ossifications and their frequent concomi- tant, angina pectoris. For the gouty habit is in general accompanied with a morbid degree of ple- thora, and consequently with over-tension of the arterial system, leading to ossification. It may be remarked, finally, that even they who attribute all the morbid alterations in arteries to inflammation, admit the necessity of specific in- flammations to account for those alterations which are not normal products of ordinary inflammation. I Thus Kreysig thinks that calcareous incrustations are only produced by gouty inflammation ; and Bouillaud, who employs the word inflammation [ in perhaps too extended a sense, believes that there ' must be a peculiar predisposition for each effect of the one same cause,—that every variety of de- position must be the result of a different specific i inflammatory action. Symptoms and diagnosis of acute Arte- ritis.—The diagnosis of arteritis is one of the most difficult in the range of medicine; as the malady presents no signs that are peculiar to itself, and distinguish it from other diseases. We shall first describe the signs by which some authors have imagined that they could detect acute aortitis, and then subjoin the sources of fallacy to which, according to our experience, those signs are liable. The practitioner, being thus warned against the various causes of deception, will be better able to give their full value to the signs themselves ; and he may in this way, we think, : make out the diagnosis with some success. The principal sign of acute aortitis, according to authors, is a pulsation of the aorta much more [ violent than in the healthy state. A pain and ; sensation of heat in the region of the aorta, anxi- ARTERITIS. 169 ety, and faintishness, are symptoms of a less con- stant nature, but which, nevertheless, it is import- ant to mark. To these are to be added accelera- tion of pulse, heat, and dryness of the skin, thirst, anorexia, and all the other concomitants of phlo- gistic action. The position of the thoracic aorta is such that the strength of its pulse can only be explored in the hollow at the summit of the ster- num and above the clavicles. The beating of the ventral aorta may be more easily examined, name- ly, by applying the hand, or, what is better, the stethoscope, on the abdomen. Violent pulsation of the aorta from inflamma- tion is often accompanied with a similar pulsation in any or all of the great arteries ; the reason of which is, that the inflammation not unfrequently extends to the other arteries, and even to the whole of the arterial system. With respect to inflammation of the internal membrane of the heart, it is excessively rare in an isolated form, being almost invariably attended either with carditis or pericarditis. Analogy indi-1 cates that it ought to be characterized by augmen- tation of the force and frequency of the action of i the heart and arteries, and leads us to expect that j when the inflammation reaches and disorganizes the muscular substance, it would render it inca- pable of contracting with its natural strength and regularity. Observation confirms what analogy leads us to foresee. In fevers, properly so called, which appear to be constantly accompanied with an irritation of the heart, the frequency and force of the pulse are the two principal phenomena that strike our senses; but should the fever assume a typhoid type, and give rise to an irritation of the heart, so profound that the muscular substance is itself attacked, the pulse loses its force and regu- larity while it augments in frequency, an unex- pected death often terminates this always formi- dable complication. Should the patient recover, the slowness of his convalescence and the fre- quency of pulse which characterize it, are probably dependent either on an irritable state of the inter- nal membrane left by the inflammation, or on soften- ing of the muscular substance,—a subject to which we shall revert when treating of softening. Such are the symptoms of acute arteritis as- signed by authors. The fallacies to which they are liable are so numerous that many able practi- tioners formally avow their inability to make the diagnosis. The fallacies arise, 1st, from the in- flammatory complications with which arteritis, and more particularly aortitis, is accompanied : 2dly, from affections which, though unattended with arteritis, occasion arterial pulsation. 1. The inflammatory complications of aorti- tis___Acute aortitis is very rarely known to exist (so far as we can judge from its anatomical ves- tiges—the only positive criteria) independent either of continued fever, or of inflammation of some of the principal viscera, particularly the lungs, j pleura, and pericardium. In these complicated cases the symptoms of aortitis are lost in those of the concomitant malady, which is of itself capable of producing, to a greater or less extent, the same violent arterial pulsation and the same anxiety and faintishness as are considered characteristic of aortitis. Vol. I—22 p 2. Affections which, though unattended with arteritis, occasion arterial pulsation. (a.) When the interior of the ascending por- tion, or arch of the aorta is ossified or cartilagi- nous, there is generally a preternatural pulsation above the clavicles, and this always takes place when the artery is dilated ; for, as the blood per- meates the diseased or dilated portions with greater difficulty than others, in consequence of its being reverberated in counter-currents and eddies from prominences in the vessel, those portions sustain, at each contraction of the heart, an increase of the expansive force of the blood, the lateral pressure of which is always augmented in proportion as the direct current is impeded. (b.) Persons of an irritable temperament, espe- cially delicate hysterical females and hypochon- driacal males, are subject to morbid arterial pulsa- tion, sometimes confined to the aorta alone, and sometimes universal throughout the system. When it is seated in the descending aorta, the patient complains of " a fluttering " in the epigastrium. (c.) Morbid arterial pulsation is a phenomenon of reaction after loss of blood—a fact to which the attention of the profession has been drawn with great ability by Dr. Marshall Hall, and which we have verified, not only by observations on the human subject, but by extensive experiments on animals, performed in concert with that gentleman. The pulsation not unfrequently supervenes, and subsists for a considerable time, after the free de- pletions necessary for the cure of acute inflam- matory affections, as pleuritis, pericarditis, peri- pneumony, phrenitis, peritonitis, &c. In these cases it would be a dangerous error to suppose that the pulsation depended upon aortitis. (d.) We have found arterial pulsations to ac- company adhesion of the pericardium, especially for the first year or so after the attack of pericar- ditis which occasioned it. The phenomenon is attributable to the jerking and, as it were, spas- modic manner in which the heart contracts under such circumstances. It may be remarked that there was adhesion of the pericardium in two of the three cases from which more especially Bertin and Bouillaud derive their opinion that aortic pul- sation is always a sign of aortitis. (Bertin, Obs. xxvii. xxviii. and xxix.) (e.) Tumours, serous effusions, &c. in contact with the aorta, give it the character of preternatu- ral pulsation, as they transmit its impulse more strongly than the parts which properly environ it The mode of distinguishing these pulsations is treated of under the diagnosis of aneurisms of the aorta. From this long catalogue of fallacies it will be apparent that the diagnosis of arteritis is beset with much difficulty. Still, it is not wholly hope- less ; for, by a negative process,—by ascertaining that the pulsation is not attributable to any of the causes mentioned,—I believe it is possible to form an opinion which will not be very wide of the truth. Of chronic arteritis, it is sufficient to say, that, though it in all probability deteriorates the general health, it presents no distinctly appreciable signs but those of the structural alterations,—the depo- sitions, dilatations, and valvular obstructions,—to which it gives rise. 170 A ITISANS, (Dioi^ASiSS OF) Prognosis.—Arteritis is not a dangerous dis- ease by its immediate effects ; but it may lay the foundation of disease of the arterial coats and valves of the heart, which may ultimately prove formidable by inducing aneurism of the vessels and disease of the heart. When arteritis is com- plicated with fevers, or visceral inflammations, the prognosis must be founded on the symptoms of the latter maladies. Treatment of arteritis.—Arteritis is to be treated on the same general principles as any other inflammation; namely, by bleeding, purgatives, diaphoretics, low diet, cooling diluent drinks, and perfect tranquillity. The latter is absolutely ne- cessary, as any efforts which accelerate the circu- lation inctease the tension, and therefore the irri- tation, of the arterial system. On the same prin- ciple, remedies which calm the circulation, as digi- talis, tartrate of antimony, superacetate of lead, are useful auxiliaries when discreetly employed ; but they should not supersede the more important remedies above mentioned, nor should they be given at a late period of the disease, when the symptoms, which of themselves become compli- cated, should be kept as unembarrassed and clear as possible. When mercury is not contra-indi- cated by a strumous or shattered constitution, its exhibition to the extent of slight but prompt sali- vation, after the first violence of inflammatory action has been repressed, is attended with excel- lent effects. When arteritis is complicated with visceral in- flammation or fever, the treatment must be directed to the primary malady. J. Hope. [ARTHRITIS. See Gout.] ARTISANS, Diseases of.—The diseases of artisans must, in every civilized country, be an object of great importance, but in none can it be so important as in Great Britain, so large a pro- portion of whose inhabitants are engaged in manu- factures. In the present article we propose to give a brief account of these diseases, and to ac- company it, as far as we can, by that of the attempts which have been made to deprive the various trades of their injurious tendencies. The arrangement which we shall follow will, with some modifications, be that which was first indicated by Ramazzini, modified by Fourcroy, and again modified by M» Patissier. The ground- work of the arrangement is founded upon the causes of these disorders ; and we, first of all, have two classes. The first includes the diseases caused by moleculae, which, mixed with the air in the form of vapour or fine powders, are respired by the workmen, penetrate their organs, and dis- turb their functions. The second class compre- hends the diseases caused by excess or defect in the exercise of certain parts of the body. Under the first class are comprehended. 1. diseases pro- duced by mineral moleculae; 2. those arising from animal moleculae; 3. those which result from vegetable moleculae; and 4. diseases which are produced by the mechanical action of moleculae or fine powders, arising from mineral or vegetable substances. The second class embraces, 1. dis- eases arising from the effects of moisture and of timperature ,- 2. diseases from undue or excessive muscular exertion of particular parts or organs t 3. diseases arising from sedentary habits. Before entering thus upon the effects of peculiar substances and the effect of particular positions, a preliminary inquiry ought to be made into the consequences of labour abstractedly taken. There is unquestionably considerable difficulty attending it; but yet it seems impossible to reject over-con- finement alone, or over-exertion alone, as produc- tive of severe maladies. We are accustomed fre- quently to witness the consequences of over- working that most useful animal, the horse ; and, in this respect at least, there is nothing physically different between man and the other mammalia. In the horse, the kind of labour has evidently nothing to do with it, since the same exercise, moderately taken, contributes to the preservation of his health and the improvement of his strength; it is the quantity alone to which the injury is to be referred. The same remark holds equally good of man, but very many circumstances attending his occupations will require to be taken into account. In the first place, the quantity of labour which different individuals can undergo without detriment, will vary much with the original con- stitution of their bodies and their habits. A man of great natural physical strength, other things being equal, will perform more labour than a man of less powerful make; of two men of equal natural powers, the one, accustomed to continual hard work, will bear more than the other, unaccus- tomed to such employment; and, in the second place, very much will depend upon the quantity of nutriment which can be obtained. A more striking instance of this could scarcely be adduced, than what occurred to the persons engaged with Captain Franklin in the travels to the North Pole. We find them preserving their strength, and easily enduring the journey to the sea, though called upon perpetually to great bodily exertion; but on their return, having been for some time deprived of sufficient food, the strongest amongst them was scarcely able to carry bis gun, and not at all able to steady it, so as to obtain any of that supply which appeared within their reach. Taking, nevertheless, all these considerations in review, there are, even in Great Britain, many instances of evil effects arising from the long con- tinuance of labour—of that labour, which not only would not be injurious in a moderate degree, but would most probably conduce to the healthy action of the corporeal functions. The majority of these cases take place among children, and chiefly among those occupied in cotton manufac- tories. Upon this part of our subject we have fortu- nately some very strong evidence, and from a source which is perfectly unsuspicious. A few years ago, the injury which, it was natural to sup- pose, must ensue to young children, from too early overstraining their physical powers, engaged the attention of parliament, and, under the influence of Sir Robert Peel, a variety of manufacturers were examined, together with many of the first medical men of the kingdom. It was scarcely reasonable to expect that the former should have observed, or, if they had observed, that they would readily acknowledge, even to themselves, the ill effects which accrued to their young work-people; ARTISANS, (DISEASES OF) 171 and, accordingly, we find that, for the most part, they utterly denied that any evil had ensued from the confinement or the exertion. We are far from insinuating that, in any instance, the manufac- turers who were called stated any thing of which they did not feel themselves convinced; but accus- tomed as they must be to employ children, and little as they naturally would feel disposed to indulge in an inquiry which must necessarily take up much time, the probability is that they would be in perfect ignorance of the subject. Among them, however, we find Mr. Owen not only ac- knowledging but remedying, as far as in him lay, the evils which arise from the too early and too long employment of children. We are well aware that the Utopian visions of this gentleman will make many persons receive his testimony with deductions from its value ; but when he relates a mere matter of fact, and when this fact is in per- fect accordance with the opinions of the most enlightened medical men, we do not feel inclined to detract one iota from its force. In speaking of the children who were engaged in his manufactory at New Lanark, he says, " I very soon discovered, that, although these children were extremely well fed, and clothed, and lodged, looked fresh, and, to a superficial observer, healthy in their counte- nances, yet their limbs were very generally de- formed, their growth was stunted, and, although one of the best schoolmasters on the old plan was engaged to instruct those children, they made a very slow progress even in learning a common alphabet." We are the more inclined to confide in this statement, from having made similar ob- servations ourselves in an asylum for children, in a large manufacturing town. In this instance, the individuals were certainly properly nourished, but they were confined eight or nine hours a day in heading pins and straw-plaiting ; but this they did not commence till past seven years of age. Yet, upon an extensive comparison of them with others not so confined, we have no hesitation in saying that their growth was stunted ; the buoy- ancy of infancy, usually so remarkable and en- gaging, was lost; neither was there that freedom of action in the limbs, which, in children, is gene- rally so conspicuous. Sir Astley Cooper, who likewise gave his evi- dence before the committee, states the ill effects of confinement in still stronger terms, if possible, than Mr. Owen ; and as he asserts his opinion to be the result of extensive observation, it is parti- cularly deserving of attention. He says, "The result of confinement commonly is not only to stunt the growth, but to produce deformity, and to that point I can answer, from a good deal of experience, that deformity is a common conse- quence of considerable confinement." It does not appear that any of the other medical men, at least of those who are known to the profession, had had many opportunities of personal observation ; but their opinions, so far as they had been able to form any, coincide with those which have already been given. It must, indeed, be admitted that even medical testimony has been adduced to prove that none of these evils are present in cotton factories; but it is not with medical as with common evi- dence, where, provided there is equal integrity, the most numerous witnesses must be credited. In medicine much more is required; ability, vigi- lant observation, and great candour ; and a single witness, known to possess these qualifications, is to be listened to with much more confidence, even with regard to mere matters of fact, than a whole host of common observers. On this ac- count, therefore, even had Sir Astley Cooper's evidence stood alone, we should have been disposed to believe it rather than that of men who, how- ever respectable they may be in their own little world, are utterly unknown beyond it. The bad effects of over-exertion, however, are not confined to children, though the intemperance and irregular habits of adults make it much more difficult to ascertain them. Among the poor, the idea of having over-worked themselves is not un- common ; and, necessarily as suspicion attaches to their own evidence, many cases have occurred to us, as we feel assured they must have done to others, in which general exhaustion and debility were readily traced to this source. Such, therefore, being the consequence of la- bour, not with regard to the kind, but the degree, it forms a most important subject of inquiry, to what extent an individual may exert his physical strength without deteriorating or retarding the full development of his powers. To enter deeply into this, however, would lead us into digression from our present subject; and we must content ourselves with stating the opinion of the late most eminent physician, Dr. Baillie, and in which he was supported by Drs. Pemberton and Tuthill, Sir Gilbert Blane, Sir Astley Cooper, and Mr. Carlisle. " Seven years old," says Dr. Baillie, "is perhaps the earliest age at which children should be employed in factories; and for the first year they should not be employed more than four or five hours a day; for the two succeeding years six or seven hours a day ; afterwards they might be employed ten hours a day ; and beyond that, in my opinion, there ought to be no increase of labour." That there are extraordinary instances, in which more than the time here specified is passed in labour, is unquestionable; but these are too few in number to disturb the general accuracy of Dr. Baillie's opinion. [By the modern factory laws of England, no child under nine years of age is permitted to work at all; and before thirteen, it can only be em- ployed for nine hours a day. The necessities or the cupidity of parents, it would appear, are con- tinually inducing them to misrepresent the ages of their children ; and it has, therefore, been found desirable to discover some test by which the capa- bility of the child may be determined, without a knowledge of its age. A standard of height has been adopted by the legislature for the purpose, but upon grounds, which, physiologically consi- dered, are very erroneous ; as the tallest children are often the most weakly. (Carpenter, Principles of Human Physiology, Amer. edit p. 482: Philad. 1843.) According to Mr. Sanders, (The Teeth a Test of Age, &c: Lond. 1842,) the degree of advance of the second dentition may be regarded as a much more correct standard of the degree of general development; and it may be taken as a guide to the age, in the large mass of cases.] We now proceed to the consideration of the first class which we have indicated above, viz. dia- 172 ARTISANS, (DISEASES OF) eases caused by moleculae, which, mixed with the air in the form of vapour or fine powders, are respired by the workmen, penetrate their organs, and disturb their functions. The first order comprehends the diseases produced by mineral moleculae. 1. Mercury—The gilders of toys and buttons, glass-platers, and the workmen in quicksilver mines, are nearly the only individuals sufficiently exposed to the fumes of this metal to be affected by it; though there is no doubt that wherever any one is long occupied with mercury, the same dis- eases would occur. One of the most common consequences of exposure to mercurial vapours, is a great increase of sensibility to cold. Dr. Gosse perhaps exaggerates when he says that such workmen are so sensible to the variations of the atmosphere that they may be compared to living barometers; but we have seen several individuals who were immediately alive to very slight dimi- nutions in the temperature of the air. One in- stance is still before us, which occurred in a young lady, who was salivated by accident seve- ral years since, and who is still affected very sen- sibly by every change in the atmosphere, though she is entirely free from other complaints. The workmen who employ quicksilver are sub- ject likewise to all those diseases to which latterly the name of pseudo-syphilis has been applied, as ulcerations of the mouth and fauces, eruptions, rheumatic pains in the limbs, and, in short, all the affections which, in former times, were compre- hended under the title of cachexia. Terrible as these disorders are, there is nothing peculiar in them consequent upon the manner in which they arise; they exhibit the same phenomena, are equally distressing, and equally obstinate, as when proceeding from the internal administration of mercury for the cure of lues. The disease which seems more peculiar to the workmen who employ this metal, is that to which the name of mercurial palsy has been assigned ; and it arises very seldom, if ever, from the exhi- bition of mercury as a medicine. The attack of this disease is sometimes sudden ; more frequently, however, its approaches are very gradual : at first the workman has less control than usual over his arms ; then they are subject to slight convulsive snatches ; they become agitated, and at length are in a continual state of tremor. The tremor con- tinues to increase in intensity, if the individual still persist in his employment, and spreads from the arms, which it commonly first attacks, to the legs, and finally to the whole body. The patient is unable to execute perfectly any of the functions which require a certain muscular power, such as locomotion, mastication, any labour of hands, &c. To these succeed sometimes pains in the bowels, restlessness, delirium, &c, with great de- rangement of the general health. After a time, the latter appears to become more settled, and the patient will often live for twenty years, utterly un- able to make any useful exertion from the tremor, though in other respects tolerably well. The fol- lowing account of an instance of this disease, which occurred in a man of sixty-two years of age, and with whom it had endured for twenty- five years, will illustrate it much better than any more general description. At the time we saw him, all the voluntary mus- cles were violently agitated, so that every attempt to speak was interrupted by the spasmodic con- tractions of the jaws and tongue. His head was in a continual see-saw ; he could not hold any thing in his hands, and seemed to have no power whatever over them. Any attempt to obtain control over his muscles invariably rendered the convulsions more violent Mental agitation in- creased them. His teeth had been lost many years, but had fallen out without being decayed ; his appetite was good, and his sleep sound. His evacuations were voluntary. The disease in this individual had commenced after gilding one year, with a shaking in one knee, whence it had spread to the rest of the body. He continued to work, however, for seven years, but during that time was frequently obliged to take a glass of rum to keep his hands steady, and he always found his tremors less after taking more ale or spirits than usual; but when their immedi- ate effect was gone off, the complaint was always much more aggravated. It is generally supposed that these tremors never ensue after the medical administration of mercury, and we believe that mercurial palsy very seldom does occur under such circumstances. This is, however, perhaps to be attributed to an insufficient quantity being taken, or the medicine being suspended after some time. It is certainly no unusual occurrence to find patients, who have been subjected to mercurial courses, exceedingly sensitive, and we once saw the tremor established in a child, to whom a considerable quantity of calomel had been given for incipient symptoms of hydrocephalus. Long as the origin of the mercurial palsy has been known, we are yet unacquainted with any treatment which is capable of removing it. The French prescribe, as usual, their tisans, but with- out much effect. In recent cases, the tremor van- ishes spontaneously, provided the patient ceases to be exposed to the mercurial vapour. Dr. Lett- som thought sulphur was a specific against it; De Haen, according to Dr. Bateman, placed much confidence in electricity ; and Mr. Pearson says, " that a free exposure to the open air during a dry state of the atmosphere, whether hot or cold, is, on the whole, the most effectual mode of de- purating the habit from a mercurial impregnation." The Cavalier Sementini, in the eleventh volume of the Giornale de Fisica, has given five instances of the successful treatment of this disease by the nitrate of silver. He began with the eighth of a grain ; and by the time three grains a day were given, the good effects were manifest, and in twenty days more the man was perfectly cured. We have never yet tried the nitrate of silver, but every other plan has appeared to us entirely use- less ; and we are inclined to believe, that after obviating the effects of constipation, or opposing any other symptom that is prominent, complete abstraction from the mercurial vapour is alone ser- viceable. In time the effects in recent cases wear off; but when an individual has once been seized, he is very liable to a relapse upon exposure to the original cause, and hence his former employment ought not to be resumed. Various plans have been suggested to obviate ARTISANS, (DISEASES OF) 173 the ill consequences attendant upon the employ- ment of mercury, and so far as regards button- gilding, the success has been tolerably complete ; at least, if it is not so, it is to be attributed to the inaccuracy of the apparatus and the negligence of the workmen, rather than to any thing wrong in the principle of the operation. In order to ex- plain this, it is necessary to take some notice of the process of gilding. This may vary a little in the different workshops as to the minutiae of the art, but not in any material respect. Our account is taken from the inspection of two extensive manufactories, one of buttons, and the other of gilt toys. There are two parts of the process which are attended with danger from mercury, but in very different degrees. The first and least injurious, and perhaps not at all injurious if the workmen are clean in their habits, is the application of the amalgam to the metal. This, which consists of gold and quicksilver, is thrown into a small quan- tity of solution of mercury in nitric acid in button- gilding, and the buttons are stirred in it; in toy- gilding, the amalgam is generally diffused with a brush. As little, if any, of the quicksilver is vaporized during this process, the principal dan- ger arises from the workmen unnecessarily touch- ing the materials with the naked hand, and not exerting sufficient care to make thorough ablutions before taking their meals. The next process, which consists in driving off the mercury by heat, is highly dangerous, in the old and common method of gilding. This, which is technically named cap-and-pan gilding, is effected over an open stove fire. The articles are placed in a common frying-pan, and every now and then are taken off and shaken in an old hat. During the whole of this time the mercury is very imper- fectly carried up the chimney, and, consequently, its fumes reach the workmen, more especially when the materials are in the hat. This plan is now followed in the gilding of toys; but in button- gilding an apparatus has for some time been em- ployed, to which, if well executed, it seems scarcely possible to add any thing. For this pur- pose, the buttons are enclosed in an open wire cylinder, which is then introduced into another cylinder formed of iron, communicating with a flue, and placed over a stove. At the entrance are folding doors, with a small opening for the iron rod, which passes through the wire cylinder, for it to rest upon, and the wire cylinder has like- wise a support at the opposite end, so that it may be revolved within the iron cylinder by the work- men. The latter commonly stand several feet distant from the stove. When this apparatus is properly made, the draught of air is very great, and it seems scarcely possible for those employed to be at all subjected to the fumes of the mercury ; and we believe that it very rarely happens that the workmen become disordered where it is used. It is somewhat unfortunate that the same plan cannot be employed in toy-gilding, or that it is not; for we confess we are not ourselves aware of any really well founded objection to it. Even, however, when the old mlthod is employed, there is great reason to believe that the serious evils attending it, arise for the most part from the carelessness of the gilders themselves. As some corroboration of this opinion, we may state that we have just seen a gilder who has now been in the business for thirty-eight years, and the great- est part of this period he worked at a common stove, but without experiencing a single inconve- nience during the whole time. His appearance was remarkably cleanly ; and being an intelligent man, we asked him the principal source of the mercurial tremors, and he answered, the careless and uncleanly habits of those employed. He himself had always been accustomed to frequent ablutions, and had never eaten without this pre- caution. This instance does not, of course, prove that the evil effects of the mercurial vapours can always be avoided by these means, but the obser- vation of most manufacturers might be citen in proof of the workmen usually neglecting them. It would not, perhaps, be quite fair to omit here the notice of M. d'Arcet's " Fourneau d'Appel," especially as the Academie Royale des Sciences de l'lnstitut de France awarded the prize of 3000 francs, left by M. Ravrio, for the invention ; al- though, with due deference to such enlightened judges, we are far from thinking that it will, in any great degree, be efficacious in lessening the evil. The principle consists in increasing the draught of the stove chimney, by rarefying the air at a certain distance above the fire. That we may not ourselves misrepresent the apparatus, we copy the following account from M. Patissier. " II imagina de construire un fourneau dit d'Appel, dont le tuyau sVuvre a une distance calculee dans la cheminee, et dont la chaleur, dilatant l'air de celle-ci, augmente son tirage. En m6me temps on place a une fenetre un vasistas; il s'etablit alors dans l'attelier un courant ascenscionel, qui entraine avec rapidite dans la cheminee les vapeurs et les gas nuisibles." There are two most power- ful obstacles to the efficacy of this plan ; the first is, that, in the common method of driving off the mercury, which alone seems to be known in France, the articles are frequently removed from the draught for the purpose of shaking them, and this when the metal is still in a state of vapour; and the other is, the additional expense which it entails; which, in a country not subjected to the perpetual interference of a police in its private affairs, would be a great obstacle to its adoption, and go far to annihilate the trade of those who were compelled to adopt it, while others were not under a similar compulsion. How far in France the recondensation of the mercury may compen- sate for the additional expense, we do not know ; but in England, where this has been long effected, it could, of course, be no recommendation. Upon the whole, we believe the cylinder to be fully adequate to its intention, and we are convinced that nothing but prejudice prevents its application, under such modifications as might be found neces- sary, to every species of gilding in which mercury is employed. The next metal, of which we shall consi.ler the injurious effects, is lead, which, both fi-m the serious diseases it induces, and its extensive em- ployment, may be viewed as the next in impor- tance to mercury. 2. Lead. — The workmen employed in lead mines, those who purify it, cast it, in short all who use its various preparations in the arts, are exr 174 ARTISANS (DISEASES OF) posed to the deleterious effects of this metal. Sir John Sinclair asserts that one labourer in three dies annually in the manufactories of the carbo- nate or common white lead. Lead is particularly dangerous in a state of fusion ; its particles pene- trate into our organs through the pulmonary and alimentary passages, and by the skin. The work- men are consequently subject to colic, and to a particular species of palsy. The class of people most subject to these com- plaints are plumbers and glaziers, painters in oil and water colours, type-founders, and colour- grinders. But though these are the principal persons liable to be injured by lead, we frequently find the peculiar diseases among other classes. Excepting, however, in particular idiosyncrasies, the same remark may be applied here as in the case of mercury, viz. that very much depends upon the cleanliness of the workmen. Dr. Fothergill has given a curious illustration of this in a young artist, who was in the habit of sucking her pen- cils ; and, on the authority of Dr. Heberden, he attributes many of the diseases of children to their being permitted to play with painted toys, which they are constantly putting to their lips. Sir George Baker has recognised lead as the cause of the Devonshire colic; and it has been remarked that the use of leaden pipes for the conveyance of water employed in cooking, is not unoften the source of the same complaints. Particular indi- viduals are much sooner affected than others by this metal, as happens likewise with mercury. Thus, to reside in a newly-painted house will immediately excite, in some persons, the colica pictonum, as it has been termed, or dry belly-ach. [The workers in white lead appear to be most subject to the disease; and the more volatile the lead is rendered, the more readily does it ap- pear to affect the system. Painting the "dead white," or " statuary white," according to Dr. Stokes, (Lectures on the Theory and Practice of Physic, 1st Amer. edit. p. 180,) is the most dele- terious form of using lead, to the house-painter. In this case, white lead is used, combined with a large proportion of oil of turpentine ; and the outer air is excluded as much as possible, so that the air of the apartment becomes strongly impreg- nated with the lead. It would seem, that the deleterious effects of lead are chiefly produced by the carbonate.] The following account we copy from Dr. Pem- berton, as being more concise than that of M. Patissier, not to say also more correct. " The complaint (colica pictonum) is known by a vio- lent and constant pain about the navel, with a retraction of the integuments towards the spine, by an obstinate costiveness, and by a frequent but ineffectual desire to evacuate the contents of the bowels. There is sometimes, though not always, considerable retching ; and when vomiting takes place in this disease, what is thrown up is usually of a green colour. This is a state of the complaint which will last for several days, during which time, however, the pain will vary somewhat in degree, though never entirely cease. A mild kind of delirium, nay, a perfect mania, will sometimes take place, and continue the whole time the bowels are constipated. These, however, are not very common circumstances; and when they do occur, they seem to have no influence in retarding the patient's recovery. In this disorder, the greatest relief from pain is experienced by keeping the trunk bent upon the knees. The pulse is usually not more than a hundred in a minute. The tongue has a natural appearance, and is moist; and there is scarcely any fever. The situation of the pain round the navel, the retraction of the belly, the costiveness, the absence of fever, the pulse, and the preference given to a bent position of the body, will distinguish this from every other disease of the abdomen." The treatment of colica pictonum consists in evacuating the bowels, for which purpose castor-oil is commonly chosen, assuaging the pain, if necessary, with opium; and in most cases this practice will succeed. (See Colic) When the colic has endured for some time, and occasionally when it has not been present, there results a peculiar species of paralysis, which affects the superior extremities only — very rarely the inferior. For the best description of the limb in this state, we are indebted to Dr. Pemberton, as likewise for a method of remedying it. The wrist, says Dr. Pemberton, in many cases of this paralysis, becomes remarkably flaccid and loose, as if the weight of the hand had stretched the capsular ligament. The adductor muscles of the thumb gradually waste away. This is sup- posed to arise from a more rapid absorption of the part taking place, in consequence of pressure from the handle used in painting; but the wasting being observed equally in each hand would rather militate against such an opinion. Dr. P. states that he had long thought some assistance of a mechanical nature might be applied likewise for the purpose of relieving the topical paralysis, by placing the muscles in such a state as that they might again be enabled to resume their lost action. Having formed this idea, he proceeded to put it to the test of experiment upon a man who was per- fectly paralytic in both wrists. For this purpose a splint was framed ; and for the manner in which it ought to be applied, we must refer to Dr. Pem- berton's book. The result, however, was most satisfactory. In nine weeks the extensor muscles of the right hand, to which the support had been given, appeared to have entirely regained their natural strength; while the left, which had not been splinted, remained perfectly paralytic. The splint was now applied to the left hand, and in seven weeks the power of the extensor muscles of that hand also was perfectly restored. It is not to be expected that even this plan will be uniformly successful ; but we have no hesita- tion in saying that it has made a disease for the most part manageable, which was formerly pecu- liarly obstinate and hopeless. With respect to preventives, we have very little to say; perhaps nearly every thing may be included in one word, cleanliness, frequent ablution, and, as far as possible, frequent change of linen. [Since proper precautions have been taken in some of the large smelting establishments of Great Britain, it has been found, that much fewer cases of lead paralysis and lean* colic have occurred than formerly. These precautions consist in compel- ling the workmen, before going to their meals, "to change their clothes, and to carefully wash their ARTISANS, (DISEASES OF) 175 hands with the aid of a nail-brush, so as to remove every particle of the metal, and thus prevent it from entering the digestive organs along with the food. It is affirmed, too, by M. Brechot, (An- nates d'Hygiene, t. xii.) that in the white lead manufactories, the superintendents, who do not handle the lead, escape the disease. (Guerard, Diet, de Mid., 2de editxxvi. 105: Paris, 1842.) Still, lead cachexia occurs at times, notwithstanding every precaution ; and there is great reason to believe, that the channel, by which the poison is often received into the system, is the air passages. Recently, sulphuric acid lemonade has been largely employed as a preventive of lead cachexia, in the laboratories of Paris. It has likewise been extensively used by Mr. Benson, the managing director of the British white lead works at Bir- mingham, in the form of sulphuric beer, and with great success. It acts, he conceives, by converting the poisonous carbonate into the innocuous sul- phate of lead. (Lond. Lancet, Dec. 17, 1842, p. 435 ; and Dunglison's Practice of Medicine, 2d edit p. 170: Philad. 1844.] 3. Copper---Extensively as this metal is em- ployed in the manufactories of this country, and though we have long been acquainted with one of the greatest manufacturing towns in Britain, we have not had many opportunities of seeing any complaints among the workmen which could be unequivocally referred to it M. Patissier says that they become prematurely old, and are meagre and unhealthy in their aspect. To a certain degree this is true, but we believe it is to be referred partly to their confinement, though chiefly to their intemperance. It does occasionally happen that they are attacked with colic, but the number is comparatively small. The disorders of the chest, to which the filers of copper are subjected, are not, we believe, owing to the quality of the metal, but merely to mechanical irritation, and are common to a considerable class of workmen who make no use of copper. The brass-founders frequently become asthmatic ; but does not this arise from the vaporization of the zinc or speltre, which they consequently inhale } We suspect it does. 4. Arsenic and antimony are not so extensively used as to give rise to any disorder, though they are employed but in comparatively minute quanti- ties in a great variety of the arts. Tin, though highly noxious when oxidated, as proved by Or- fila, has no effect in its metallic state, and we have never seen any tinmen whose complaints could be traced to their work. 5. The manufacturers of mineral acids, which all emit very acrid vapours, are liable, without care, to be asphyxiated, and to severe pneumonic affections, from respiring these vapours. By ope- rating, however, nearly in the open air, and taking merely common precautions, every ill effect from these sources may for the most part be obviated. The dippers in brass-foundries and gilding manufactories, that is, those who prepare the articles for the gilding, by cleaning them in aqua- fortis, are liable to the same diseases, without due caution. Formerly, indeed, they frequently fell victims to their occupations ; but this process having latterly boon conducted, for the most part at least, in the open air, the danger has much diminished. The impunity with which the labour- ers may work is, however, manifestly dependent upon their own conduct. We scarcely know whether the accidents to which those who use the mineral acids are sub- jected ought to be mentioned here, as, with a very slight degree of prudence, they may be entirely avoided. The second order in the first class comprehends the effects of animal moleculae, during their de- composition, and upon few subjects have more erroneous views been entertained. The nightmen of Paris, who are employed to empty the immense fosses daisance of that metro- polis, have long been acquainted with the dangers arising from the evolution of the gases. These have been divided into two kinds, la mitte and le plomb. The mitte is caused by ammoniacal vapours. The plomb is commonly formed by the sulphuretted hydrogen and hydro-sulphuretted ammoniacal gases ; at other times by azote. La mitte is announced by a sharp odour, which occasions a smarting in the eyes ; very soon, the globe of the eye and the pupils become red ; at the same time there is an uncomfortable feeling about the nose, discharge, and pain, which, beginning in the orbit, extends to the forehead. To this state a blindness is often added, which endures for one or two days. The patients then experience severe pains, and are unable to support the light; they become restless, and receive no relief till tears flow. If the ophthalmia is slight, it is speedily removed by shading the eyes and exposing them to the open air ; if it is intense, the nightmen are accustomed to wash their eyes with cold water, to apply compresses upon the pupils wrung in the same liquid, and to remain in bed in a dark chamber. Dupuytren and Barruel have observed that le plomb produces two distinct affections — the one, the most common and the most terrible, caused by the sulphuretted hydrogen and hydro-sulphuretted ammoniacal gases, is accompanied by convulsions; the other, true asphyxia, from the want of respir- able air, is caused by azotic gas, and is character- ised by stupor. The evils arising from the latter gas can only be removed by a free circulation of air, or perhaps, if it were possible, by adding a quantity of oxygen gas. But with regard to the former, the discovery of M. Labarraque in the disinfecting powers of the chloruret of lime and soda, has removed every danger, excepting that which may arise from com- plete negligence. The mode of employing these substances is by pouring them in solution upon the reservoirs or privies in which the matter evolv- ing the gases is contained. An easier mode, and considering the cheapness of the chloruret of lime, one which will more commonly be followed, is to throw the chloruret in powder into the apartment; and, from experience, we know this to be efficient We refer the reader, however, for a more extend- ed account of the manner in which these chloru- rets should be employed, to Mr. Alcock's essay on this subject, which contains both the fullest and the best statement that has yet been made. It will readily be perceived that the animal efflu- via to which the class of workmen just alluded to are exposed, differ much from every other in the more complete decomposition which the matter has 176 ARTISANS, (DISEASES OF) undergone, and the greater accumulation of the resulting gases. Butchers, chandlers, &c., respire these gases much more diluted with air, and ap- pear not to be afflicted by any diseases in conse- quence of them. We are much disposed to be- lieve that the disagreeable odour of the workshops has been the principal reason of their reputation for unhealthiness : this opinion is confirmed by the testimony of Dr. Bancroft, who has collected many facts in corroboration of it Besides others, he mentions the establishment of a manufactory of adipocire at Conham, near Bristol, which was not in the slightest degree injurious to the neigh- bourhood, though the smell was most offensive. To these he added his own experience at Rosetta, where he was daily exposed to the effluvium of putrid bodies, and felt no inconvenience; and a communication from Mr. Lawrence, in which that gentleman says that his experience, as demonstra- tor at St. Bartholomew's Hospital, was strongly corroborative of the opinion that putrid animal effluvia are not usually detrimental to health. That animal effluvia are not, in this diluted state, productive of fever, we may mention an- other proof which is within our own knowledge, and which we know would be confirmed by all the medical men acquainted with the spot. In one part of the populous town of Birmingham, many slaughtering-houses were congregated ; and yet, if any situation in the town could be men- tioned in which the fewest cases of fever have occurred, it is in their neighbourhood. M. Patis- sier bears his testimony to catgut-makers not being liable to putrid and malignant fevers, and gives what he believes the explanation of it. " S'ils ne sont pas sujets aux fievres putrides et malignes, c'est qu'ils travaillent dans des lieux ouverts, ou 1'air circule librement" We believe, that the pallid countenance, languid appearance, and swelled legs, are neither peculiar to catgut-makers, nor the con- sequence of their employment; although this au- thor intimates a connexion between these circum- stances and the occupation. [It has been supposed that putrid animal exha- lations are a common source of fever — intermit- tent, remittent, and continued — yet it would not seem that disease of any kind is often produced from this cause. It may, indeed, be affirmed, as the writer has done elsewhere, from numerous observations, (Dunglison's Elements of Hygiine, p. 108 : Philad. 1835,) that in the vicinity of the workshops of the " knackers,"—whose occupation it is, in the large cities of Europe, to convert the dead horse to useful purposes, cats' and dogs' meat, bones for the distillation of hartshorn, &c.__ although the atmosphere is intolerably fetid to the casual visiter, neither the workmen nor the fami- lies around are liable to malarious, or to any dis- order, which can be fairly referred to that cause; that in the year 1828, a committee was appointed in Paris, to inquire into the circumstances con- nected with the operations of the knackers ; and every one examined by the committee agreed that they were most offensive and disgusting, but no one that they were unwholesome; nay, it was even inferred, that they were conducive to health, as all the men, women, and children, concerned in the works, had unvarying health, were remarka- bly well in appearance, and strong in body, the1 workmen commonly attaining old age, and being generally free from the infirmities that accompany it; and when an epidemic fever was in full force, not one of the workmen in the establishment of Montfaucon was affected by it; that, as already remarked, the gut spinner, whose occupations prior to the discovery by M. Labarraque of the disin- fecting power of the chlorinated preparations, were most offensive, owing to the putridity of the ma- cerated intestines, enjoyed remarkable health ; and lastly, that although the tainted air of the dissect- ing room is breathed month after month, and for many months, by hundreds of students in differ- ent parts of the globe, no epidemic fever or spe- cial disease is generated. All these affirmations have been since confirmed by a hygienist of distinction, (Parent Duchatelet, Hygienepublique, Paris, 1836.) In the first place, as regards the shops of the knackers, or chantiers d'iquarrissage, the filth and stench of whose ope- rations are stated to be horribly offensive, M. Pa- rent describes the establishment of Montfaucon, to which allusion has been made, as immense, the number of horses taken to it, either dead or to be killed, being twelve or thirteen thousand annually. The men are described as enjoying the most flour- ishing health, the women as most fruitful, and the children as pictures of healthful energy. Of the health of the manufacturers, he speaks in equally strong terms; and he adds, that the workmen in the chantiers were remarkably exempt from dis- ease during the prevalence of cholera in Paris. There were fewer fever patients admitted into the Hopital Saint Louis, which is situate in the dis- trict of the chantiers, than into any other hospital of the metropolis. As respects the dissecting rooms, a wide field is afforded in Paris for testing whether they be unwholesome to the students and attendants, and to the inhabitants in the vicinity. M. Parent un- hesitatingly expresses his conviction that there is no ground for the belief that the dissecting rooms are foyers of morbid emanations. In support of this opinion, he adduces numerous facts, and the decided opinions of Lallemand, Desault, Dubois, Dupuytren, Boyer, and many others ; and as re- gards the effect of the dissecting room on the health of students and persons attached to and employed in them, his testimony is no less une- quivocal. He states, and brings forward the tes- timony of Messrs. Andral, Lawrence, and others in confirmation, that there is no disease whatever to which they are liable from the cadaveric ema- nations ; that gastro-enteritis, meningitis, and ty- phoid fevers are very frequent, according to M. Andral, among the students during their first year's residence in Paris; but these diseases depend so little upon the mere circumstance of dissecting and remaining in the dissecting rooms, that they are more common amongst those who have not begun to dissect Desault was in the habit of say- ing that he firmly believed the air of the dissect- ing rooms had saved him from attacks of epidemic and other diseases, of which those hospital physi- cians and surgeons, who seldom or never dissect- ed, appeared to be much more susceptible than he. (American Medical Intelligencer, for 1838, p. 162.)] But though observation appears to warrant the ARTISANS, (DISEASES OF) 177 conclusion that butchers are not subject to fevers, I nor to any other disorder which can be properly referred to putrid effluvia, there seems some doubt whether they do not too freely absorb nutritive particles, as they are particularly liable to the dis- eases arising from plethora, more especially deter- minations of blood to the head. The principal circumstance adduced as giving some probability to this notion, is, that cooks, whose appetites are proverbially bad, evince the same symptoms, and frequently fall victims to the same maladies. We are inclined to believe, however, that some errors exist in both cases. From the facility with which butchers can obtain animal food, they usually much indulge in it, and many have acknowledged to us that they are in the habit of eating it three times a day. The business of a cook, likewise, compels him to be perpetually tasting the various dishes which he is composing, and it is impossi- ble to say how much is in this manner consum- ed ; at any rate, the food is subjected to the sto- mach in the mode most favourable to digestion, and its nearly total conversion to the nutrition of the body. Butchers evidently enjoy immunity from con- sumption. M. Patissier says, " On a remarque qu'ils meurent rarement de le phthisie pulmo- naire." Dr. Withering has stated, in a letter to Dr. Beddoes, which was published by the latter in 1793, that butchers and the makers of catgut are exempt from consumption. To these classes Dr. Beddoes has added, from information otherwise obtained, soap-boilers, the fishermen and the fish- wives who live in the neighbourhood of Edin- burgh. From our own experience in a dispensary of considerable extent, we believe that these re- marks are correct; chiefly, however, with respect to tubercular consumption. From those affections of the bronchial tubes which were formerly con- founded with phthisis, we do not think they are equally free. We shall dismiss, with a very few remarks, the remaining orders of this class. They refer chiefly to the diseases incident to medical men, and to those persons who are employed in attendance on the sick. It is generally admitted that in few in- stances have the disorders to which such individ- uals are subjected been accurately traced to their employment, excepting those which have evidently their origin in contagion or infection. With re- spect to anatomists, their diseases are chiefly the results of accident, and diarrhoea occurs in those who are unaccustomed to dissection : as to the adage of physicians, "aliis inservendo consumun- tur, aliis medendo moriuntur," we suspect that there are many young physicians waiting for the exit of their aged brethren, who would be able to contradict it With regard to the operation of the third order of the first class, viz. vegetable moleculx, we shall find that some of them affect the system mechani- cally only, that is, by producing local irritation, which, however, is not influenced by the specific properties of the impinging particles. Others, on the contrary, act by virtue of certain peculiar qualities, and from which peculiar disorders arise, which no other substances have the power of exciting. These circumstances are equally true of mineral substances employed in the arts; but Vol. I. —23 we thought it better to delay considering the action of mineral particles as mechanical irritants, till we could notice, at the same time, the effect of vegetable particles, especially as, in this respect, they differ little, if at all, from each other. We shall first notice the maladies of those workmen which arise from the quality of the vegetable substance upon which they operate. Few vegetable substances employed in the arts appear to act chemically, if we may so express ourselves, upon the animal system ; perhaps the only un- doubted instance is snuff. This, however, acts mechanically also, by affecting the air-passages. Its peculiar property induces headach, vertigo, nausea, and perpetual sneezing. [Parent Du- chatelet (Annates d'Hygiene, &c. p. 1,) believes, that the manufacturers of snuff suffer slight incon- venience from the reduction of the tobacco to powder (la demolition des masses), but not in any other manner.] The bakers' and grocers' itch appear instances of local diseases arising from the peculiar quality of dough, sugar, &c.; but we are not sufficiently acquainted with their origin to speak decisively on this point Wine-pressers, brewers, and persons who ex- pose themselves incautiously to fermenting liquors, become sometimes completely asphyxiated by im- prudent exposure to the evolving gases. These, however, are rare occurrences. There may be other trades in which vegetable substances induce disorder by virtue of their peculiar properties, but we are convinced that they are neither numerous nor important. The diseases which are produced by the me- chanical irritation of moleculae or fine powders, are, unfortunately, numerous. The artisans who suffer from this cause, are sawyers, millers, starch- makers, flax-dressers, weavers, wool-carders, fea- ther-dressers, horn and pearl-makers; needle, edge-tool, and gun-barrel grinders ; iron and brass filers, with many others. These are the principal labourers included in this order, but they are affected by their occupation in very various de- grees. That some owe their complaints, and too frequently their deaths, to their employments, there is not the slightest question ; and of these, sawyers and millers, iron and brass filers, suffer the least. Then come horn and pearl button- makers ; and, among the grinders, it would be difficult to say which are the most afflicted. They are universally short-lived. The diseases to which these workmen are sub- jected are entirely such as affect the air-passages ; indeed, we might say the disease, there being scarcely any other than that, to which the accu- racy of modern pathologists has given the name of chronic bronchitis. It is known among the different grinders under various applications, as " pointers' cough," " grinders' rot," &c. There is nothing peculiar in the symptoms or progress of the complaint, when it has once commenced ; but knowing the cause, we feel somewhat surprised that it does not attack them sooner, or that it should attack them at all. It is true that few of these mechanics live beyond thirty or five-ana- thirty years of age ; but till the last of their lives, they are seldom inconvenienced in any material degree. This, at least, is correct of the grinders ; 178 ARTISANS, (DISEASES OF) but in the horn and pearl button-makers it fre- quently affects them early, endures for many years, and, finally, assumes rather the character of asthma than of consumption. All these work- men have frequent recurrence to emetics, and it is very questionable if a better practice could be ad- vised. We have ourselves had repeated opportu- nities of observing their efficacy, and we make a constant practice of prescribing one whenever an individual, affected by his trade, presents himself to us. The tartar emetic ointment, also, has ap- peared of great service, when used to the extent recommended by Dr. Jenner; but when only applied for a few days, we have never perceived the slightest benefit to be derived from it. Upon the whole, however, the treatment varies nothing from that which the disease requires when excited by other causes. Some of these workmen are likewise subject to inflamed eyes, from the particles impinging the conjunctiva ; but these cases are not so numerous as might have been expected. It is gratifying to be able to state that human ingenuity seems at length to have invented an arrangement which, under some modifications, may remedy the evils of these most injurious oc- cupations. The liability of the needle-pointers to consumption was remarked by Dr. Johnstone many years ago, and he proposed a muzzle of damp crape to arrest the particles ; Dr. Gosse, a sponge ; and M. d'Arcet, his " fourneau d'appel." Whether any or all of these would be effectual, we have no means of ascertaining, for the work- men would never apply the former constantly, and the latter has never been tried in this country at all. To Mr. Abrahams, of Sheffield, however, we owe an invention, which it appears to us can only fail of success from inaccuracy in its arrangement, or negligence in employing it. For the particu- lars of this invention, we refer our readers to the forty-second volume of the Repertory, and shall here only extract some of the testimony in its favour from a vice-president of the Society for the Encouragement of Arts, and some of the grinders themselves. " I have no hesitation," this gentle- man says, " in stating my opinion, that, whether considered as a novel and ingenious apparatus of the mysterious power of the magnet, or with refer- ence to the more important object of alleviating one. of the evils incident to some of our manufac- turing processes, and thus rendering them con- sistent with the paramount claims of humanity, this invention Tanks as high as any that has ever been submitted to the Society." Messrs. Cocker & Son, of Hathersage, observe that " the pointer who has most frequently tried your magnets, states that, with the use of them and the damp- bag which he has suspended over the stone, he had not more dust, &c. floating about him in a whole day, than he used to have in a quarter of an hour." This invention appears to us the more valuable, as one part of it may be applied to pearl button- turning, and several other processes, with very little difficulty, and with great probability of alle- viating, if not removing, the evil attendant upon such manufactures. Before leaving this subject altogether, we cannot omit to notice an invention by Mr. Jones, for gun- barrel grinding, in which no dust arose, and which, being effectuated by a machine, we should have conceived would have superseded entirely the present mode of grinding. Why it did not suc- ceed with the inventor in this country we cannot tell, unless it where " from that callous indifference of the grinders to the fate which awaits them, that their apprehensions are said to have been excited, lest Mr. Abraham's inventions should be success- ful enough to affect their wages." The conse- quence, however, has been, that the Emperor of Russia, who saw the apparatus when ill England, induced Mr. Jones to settle in his dominions; and, unless we are much misinformed, the plan alluded to is there in full operation. A local disease, which is confined to a particu- lar class of workmen, may be noticed in this place, viz. chimney-sweepers' cancer. Formerly it was supposed to arise from the qualities of the soot; but Dr. Gosse says, " the climbing-boys in Vienna, I have been told, placed in different circumstances, and not exposed to the soot of coal, present a similar disease." Of the real origin of this com- plaint, therefore, we must be considered ignorant; but that it is almost peculiar to chimney-sweepers, seems well ascertained. " It always makes its first appearance in the inferior part of the scrotum, where it produces a superficial, painful, ragged, ill-looking sore, with hard and rising edges : the trade call it the soot-wart: in no great length of time it pervades the skin, dartos, and membranes of the scrotum, and seizes the testicle, which it enlarges, hardens, and renders truly and thoroughly distempered ; from whence it makes its way up the spermatic process into the abdomen, most fre- quently indurating and spoiling the inguinal glands; when arrived within the abdomen, it affects some of the viscera, and then very soon becomes painfully destructive." Such is the de- scription given of this frightful disease by that excellent surgeon, Mr. Pott. Fortunately it is but rare; when, however, it has commenced, there is but one remedy, and that is " the imme- diate removal of the part; I mean," says the same author, " that part of the scrotum where the sore is ; for if it be suffered to remain until the virus has seized the testicle, it is generally too late even for castration." Cleanliness might, perhaps, even in this case, prevent the attack ; but in an occu- pation in which cleanliness is almost impossible, the occurrence of a disorder of such virulence ought to form a strong motive for its discontinu- ance. The frequency of accidents, and the bar- barity of master chimney-sweepers, have, we believe, very much contributed to the disuse of boys, and the employment of machinery; and heartily should we congratulate ourselves if any thing we could say should further so desirable an end as its entire adoption, and the consequent release of a number of poor objects from wretch- edness and disease. We shall now proceed to the consideration of the second class ; and, first, of the diseases arising from the effects of moisture and temperature. We very much question whether any disease whatever can be traced to moisture only, we mean to moisture unconnected with its effects upon the temperature of the body. Some proof of this seems to be afforded in the custom of Highlanders of dip- ARTISANS, (DISEASES OF) 179 ping their plaids in water before sleeping in them. A more striking circumstance, however, is that of the shipwreck related by Dr. Currie, where the ma- riners who died had been only occasionally washed by the surge, while the survivors were always im- mersed in it M. Patissier appears to have some idea ofcthe kind, for he says, " II vaut mieux travailler dans l'eau, les pieds et les jambes nus, qu'avec des gufitres et des souliers, qui ont l'inconvenient de retenir l'humidite;" and thus will continue to dissipate the heat when no longer evolved in addi- tional quantity by exercise. Under this section, therefore, we shall consider the consequences of temperature and moisture combined. The human body, we well know, is susceptible of bearing with impunity considerable extremes of temperature, if the changes from the one to the other be not too sudden. Injurious consequences arise more from imprudence than from necessity, and are particularly incident to bakers, brewers, glass-blowers, brass and iron-founders, and various other workmen. When heated with their work, they very frequently leave the shop, even in the middle of winter, without any additional clothing; thus suddenly obstructing the perspiration, and too often producing rheumatism, catarrhs, asthma, inflammations of the chest, and general dropsy. With the labourers of this class it is very evident that nothing is wanting but common prudence to prevent, for the most part, those inconveniences which must otherwise ensue from their occupa- tions. But there is another class of workmen who are perpetually exposed to a low temperature, or are obliged to remain for a considerable time together in shops overloaded with vapour, thus moistening their clothes, and rendering them rapid conductors of heat; viz. those whose occupations compel them to work in the open air, and exposed to the frequent alternations of the weather. To these classes belong washer-women, dyers, fullers, water- carriers, gardeners, milkmen, farmers, fishermen, and many others. The diseases of all these are precisely such as we are accustomed to refer to the suppression of cutaneous perspiration : and, in marshy situations, in addition to the disorders mentioned above, we have not rarely intermittent fevers. The steepers of hemp are reported to be liable to intermittents, but manifestly from the exhalation of miasmata similar to those which excite them in fens and marshes. It would be difficult to mark out any plan for removal of the latter evil, excepting that of steep- ing as little as rn^y be in one place, and thus diluting the miasmata. With regard to the former, we can only recommend the constant use of flan- nel, and perhaps a rather freer diet than is neces- sary under other circumstances. M. Patissier recommends the fishermen to cover themselves with a cloak of cerecloth, " d'une capote en toile ciree," and perhaps it may be useful to them. It is only possible here, however, to give general directions, and the indications are too plain to be mistaken by any one. [An occupation of this kind has taught us the effects produced by large quantities of fermented liquors. There is a body of men employed on the river Thames, whose business it is to raise ballast from the bottom of the river. As this can be done only when the tide is ebbing, their hours of labour are regulated by that circumstance ; and, consequently, vary through every period of the night and day. They work under great exposure to inclemencies of weather; their occupation re- quires great bodily exertion, occasioning profuse sweating, and much exhaustion. In consideration of this, their allowance of liquor is very large ; each man, according to Dr. William Budd, (Tweedie's Library of Medicine, 2d Amer. edit, iii. 587, Philad., 1842,) drinks from two to three gallons of porter daily, and generally a consider- able quantity of spirit besides. This immoderate consumption of liquors forms the only exception, as far as relates to food, which these men offer to the lower classes in London. Gout is remarkably frequent among them, and although not a numer- ous body, many of them are every year admitted into the Seamen's Hospital Ship affected with that disease. This, as Dr. Budd remarks, is a very interesting fact, and seems to show that no amount of bodily exertion is adequate to counteract the influence of such large doses of porter ; the expo- sure to wet and changes of temperature probably favouring its operation.] 2. The second order of this class comprehends those diseases which arise from undue or excessive exertion of particular parts or organs. Without following M. Patissier's division, we shall shortly treat of the effects of immoderate muscular efforts; immoderate exercise of the voice or sight; occu- pations requiring long-continued standing; and occupations which require pressure upon, or exer- cise of, some particular part. The diseases to which persons are subjected whose employments compel them to powerful ex- ertion of the muscles, are hernia, aneurisms of the heart and great vessels, hemorrhages from the nose and lungs, laceration of muscles, and not unfre- quently such injuries of the spine as to produce deformity and incontinence of urine. Of all this array of evils, hernia is the most frequent; M. Patissier mentions that the London Institution for the Relief of Ruptures received, between April 1807 and October 1808, five thousand three hun- dred and eighty-seven individuals, of whom seven hundred and sixty only were women. From the very general adoption of the steam-engine in this country for the execution of all laborious work, the sources of these accidents and diseases are daily diminishing. The French are very fond of tracing aneurisms to this cause, and it is possible that they may oc- casionally proceed from it; but we are convinced that their frequency is much over-rated. Where there is a predisposition in the blood-vessels to this disease, it may doubtless be induced by violent effort to a particular part; but from the compara- tive rarity of aneurisms in this country, and from their frequently happening in women, where this cause cannot be suspected, we are disposed to believe that they ensue only where there is such a predisposition. Of the other consequences, lace- ration of the muscles is the most frequent, and is often effected by a very trifling effort; but it is an accident of more inconvenience than importance, if treated by a well-educated surgeon. Ramazzini has affirmed that a standing posture is a no uncommon source of varices in the legs. 180 ATITISANS, (DISEASES OF) Dr. Gosse has published a similar opinion. M. Merat has remarked also, " that the footmen who stand long behind carriages on the points of their toes — the only attitude by which they can avoid the shocks — are subject to aneurisms of the pop- liteal artery." In an inquiry like the present, it is of some importance to distinguish between what is merely coincidence, and what stands in the rela- tion of cause and effect. This, we suspect, has been very frequently overlooked by M. Patissier, and, indeed, by French authors generally. We do not doubt that both Ramazzini and Gosse have witnessed varices in individuals whose general posture was standing, nor that M. Merat has seen popliteal aneurisms in footmen ; but does it there- fore follow that their occupations were the cause of the disease ? We are not aware that varices are more frequent in men than in women ; our own experience, indeed, is favourable to a con- trary opinion, and their origin we have in very many individuals traced to pregnancy. But when we consider that standing is the position which the most numerous class of workmen employ, that there is, in truth, scarcely any art in which the labourers do not stand for a very great length of time, and yet that varices are very far from bearing any proportion in the diseases of such workmen, it does appear to us that this position must be rejected as their cause. With regard to aneurisms, it is very true that Mr. Hodgson, who is the best authority on the subject, states that men are more liable to them than women ; but he likewise states a similar fact as to "those dis- eases of the coats of arteries, which precede the formation of aneurisms." This again, therefore, seems merely a coincidence. The same observa- tion applies to the occurrence of aneurism in tailors and shoemakers, in whom the citation of a single case is deemed sufficient by M. Patissier to mark it as proceeding from their employments. Housemaids, from kneeling at their work, are unquestionably liable to a swelling of the bursa of the patella. It seldom, however, proves of any serious inconvenience, though occasionally, from inflammation taking place, it becomes the subject of surgical treatment. It is sometimes early re- duced by the application of leeches, but will return soon after the patient has resumed her former em- ployment. Under the same head we may place those dis- eases which originate from too violent or long- continued exertion of the voice. The evils frequently enumerated as arising from over-exertion of the vocal organs, depend, in some measure, upon other causes than mere exer- tion. From this alone, without question, aphonia may occasionally proceed, oedema of the glottis, haemoptysis, and laryngeal phthisis; perhaps even herniae may ensue. But if cerebral congestions or aneurisms of the heart are prevalent among orators, in support of the latter of which, however, the only case that we have seen cited, is that of the celebrated Miraboau, they are rather to be referred to the effect of the passions. In the same way, M. Halle has observed that public singers are liable to a series of neivous affections ; and here M. Patissier has very properly remarked that the love of music may degenerate into a predo, minating passion. " Musicians and painters," he says, " are, in general, the most enthusiastic of all artists. We have seen musicians become de- ranged, and musicomania has been observed by many physicians." The treatment of the diseases which may be traced to the exercise of the vocal organs must plainly be commenced by a perfect abstinence from the exciting cause ; but whatever farther may be required must be dependent upon the cir- cumstances and constitution of the patient; and if the chest is threatened with any serious dis- order, which may usually be recognised by the presence of cough and emaciation, the profession which compels the exercise of the voice must be altogether abandoned. Continued and intense application of the eyes, or their subjection to vivid light, is productive very frequently of the loss of sight, very generally of a diminution of its powers. Watchmakers, micro- scopic observers, and embroiderers, are often short- sighted. " They are obliged to compress the eye by the muscles attached to the globe, and to make it, consequently, take a more convex form than usual, that they may be enabled to observe more distinctly ; and their continual compression pro- duces myopia." The workers at furnaces and iron-forges fre- quently become amaurotic, from the great glare of the fires. In all these cases there is evidently no good to be expected from medical treatment, unless the patients abandon their occupations. 3. The third and last order of this class, and with the consideration of which we shall con- clude the present article, are the diseases attendant upon sedentary habits. To enter fully into these, to show the manner in which they are adverse to health, and the proper remedies, would take up nearly as much space as we have already occu- pied. It can be only an outline which we are now enabled to offer. The diseases of literary men are those which originate from want of exercise, very frequently from breathing the same atmosphere too long, from the curved position of the body, and from too ardent exercise of the brain. Of these sources of ill health, the last is alone peculiar to them, lawyers, bankers' clerks, &c. : the former are common to them with a considerable number of artisans, as tailors, shoemakers, weavers, watch- makers, jewellers, and a variety of others. But several of these last have likewise peculiarities in their manner of working, such as keeping the body more or less curved, and pressing strenu- ously against the sternum orepit of the stomach, which materially modify their maladies. After mentioning, therefore, the diseases common to all, we shall briefly notice those which are pe- culiar. Perhaps no position, if long continued, is more injurious to health than sitting. The artisans who have practised it from infancy very rarely enjoy a vigorous constitution ; their countenances are pallid and leucophlegmatic, and they wear the appearance of old age at that period which is usually considered as middle life. " Sedentary habits," observes Patissier, " usually cause the lymphatic to predominate over the muscular, nervous, and sanguiferous system;" hence scro- fula, rickets, cachexia, &c. » Those who labour ARTISANS, (1 sitting complain of hemorrhoids and pains in the kidneys : the females are subject to fluor albus and irregular menstruation." In all these indi- viduals, the most common, the most obstinate, and too frequently the forerunner of a more fatal dis- ease, is dyspepsia. In those who are badly nourish- ed, which, however, happens rarely in the great manufacturing towns of England, it takes that form which Dr. Bateman has described under the title of asthenia. Obstipation of the bowels is exceedingly common among all, and to this is unquestionably to be traced the prevalence of hemorrhoids, and, not improbably, affections of the prostate gland. "Their position is peculiarly unfavourable to the functions of the viscera of the abdomen and chest; it determines dyspepsia, gastritis, obstipation, hemorrhoids, catarrhus vesi- cae, and enlargements of the viscera." To these we may add, and so conclude the subject, so far as this class of mechanics are concerned, that, be- sides the evils arising from their position, many make strong pressure upon the chest and the pit of the stomach. Of this class are shoemakers, weavers of all kinds, button-burnishers, &c. By this pressure, gastrodynia, to a very severe degree, is often produced, chronic inflammation of the peritoneum, and phthisis. The same evils are common, but much less intense, in bankers' and attorneys' clerks, who incautiously lean too strong- ly over the desk. Tissot has published a small work upon the Diseases of Literary Men ; and though it contains much that is fanciful, it is certainly deserving of attentive perusal. In addition to the disorders which a continued sedentary position induces, they are liable to many from a too constant exer- cise of the brain. " Severe, dry, tetrick," says the singular and facetious Burton, "are common epithets to scholars; and Patritius, therefore, in the Institution of Princes, would not have them to be great students ; for (as Machiavel holds) study weakens their bodies, dulls their spirits, abates their strength and courage ;" " they are most part lean, dry, ill-coloured, spend their fortunes, lose their wits, and many times their lives." From Aristotle downwards, the brain has been remarked to suffer peculiarly from this over-excitement; and there seems no exaggeration in the assertion, that « headachs, arachnitis, apoplexy, mania, me- lancholy, and particularly hypochondriasis, are its consequences." In the present day there is more general temperance in the pursuit of inform- ation ; there is more diversity, and usually more bodily activity. Hence, probably, the ill effects are rare. They are still, however, common ; for, unfortunately, the energy which prompts to in- dustry in accumulating knowledge is almost al- ways conjoined with great moral sensibility. The plan which has served to diminish their frequency may, perhaps, under proper management and adaptation, be successful in entirely preventing them ; and the advice of Ramazzini ought to be written up in the room of every intense student. "Nihil majus salutare censeo, ac magis commen- do, quam corporis exercitium quod nihil prestan- tius ad obstructiones expediendas, nativum colo- rem roborandum, coctiones perficiendas, trans- piratum promovendum, et scabiem fugiendam." [The diseases with which the literary are spe- • ISEASESOF) 181 cially afflicted are those to which the sedentary are liable, even when the intellect is suffered to lie dor- mant ; and, accordingly, dyspepsia and its gloomy concomitant, hypochondriasis, with general torpor of the digestive apparatus, are the common results : but these diseases are by no means liable to de- stroy ; and it may be affirmed, that literary men, as a body, attain as high a degree of longevity as men of any other avocation. In antiquity, this fact was most remarkably established, and all our associations of ancient wisdom are attached to the hair whitened by time, and to those venerable and venerated busts which exhibit the characteristics of the accumulated wisdom of ages. Germany affords an example of a class of men who devote themselves, from an early age, to literary pursuits exclusively, and their longevity has been every where a subject of comment. It has, indeed, been maintained, and with much evidence in its favour, that the pursuit of letters in Germany, as every where else, is eminently favourable to longevity. Blumenbach affirms that for the half century and more of his connexion with one of the most cele- brated universities in Europe, he had not known a solitary example of any youth falling a victim to his ardour in the pursuit of intellectual distinc- tion ; and Eichhorn, one of the most voluminous writers of his day—the eminent philologist and historian—is said to have asserted boldly, " that no one ever died of hard study." " The idea," said he, " is preposterous. A man may fret him- self to death over his books, or any where else, but literary application would tend to diffuse cheer- fulness, and rather prolong than shorten the life of an infirm man." The writer's experience is completely in accordance with that of those ob- servers. He cannot, indeed, recollect a solitary case of serious mischief induced by too great in- tellectual exercise, although the cause has not un- frequently been assigned. Where the health is apparently injured by literary pursuits, it will be found that the evil is dependent rather on collate- ral circumstances, on irregularity of habits, as re- gards eating, drinking, or sleeping, often acting upon a frame unusually susceptible of impressions, for such is a frequent accompaniment of genius ; and, that these views are just, is strongly corro- borated by examining the history of female au- thors, most of whom have been extremely long lived; doubtless, in a great degree, because they were exempt from that irregularity of life which history shows to have been so destructive to many of the poets, whose productions have appeared in youth, and the celebrity arising from which had led them into society, and into habits that have too frequently been most destructive. It is probable that literary occupations cannot be closely pursued with the same impunity in the young as in the adult When study is indulged to excess in early life, it may have a tendency to induce a predominance in the nutrition of certain organs at the expense of others. If any organ be energetically exercised, its vital activity is exalted, and a larger afflux of blood takes place towards it, so that it attains a greater degree of development than where it is less used. Hence, it can be con- ceived, that a constant over-tension of the intel- lectual powers, especially when conjoined with irregularity in exercise, diet, sleep, &c, may occa- ITES. by the intemperance of the individuals exercising them. Even the grinders, by their constant drink- ing, greatly increase the injuriousness of the small particles which they respire. The bronchial tube is already predisposed to inflammatory action, and perhaps scarcely requires the additional irritation of a foreign body. Among those who exercise their intellectual faculties the same observation holds equally good. There is indeed no ques- tion that mental exercise renders the brain in- capable of bearing that stimulus which otherwise might perhaps be borne with impunity. A few years ago a gentleman, fifty years of age, who had the care of very extensive concerns, applied for assistance on account of giddiness in his head. He did not consider himself intemperate, yet he was in the habit of drinking three or four pints of strong ale daily, and this his father, an old man of ninety years of age, had done for years without any inconvenience. The difference, however, in their habits was great. The father, concerned in agricultural pursuits, had little care, while the son was called upon to exercise his mind continually and intensely. Fortunately it was not too late to point out the error ; and a change of habits has preserved him from any repetition of the attack. Such, then, is an outline of the evils to which mankind are subjected from their occupations; and numerous as they are, it does not appear that any are really and entirely unavoidable. Ingenuity has already diminished the number, and may, per- haps, do so still farther; but it cannot be too much impressed upon all, that more depends upon the individual than upon the occupation. In many trades cleanliness will alone be sufficient; and with this and common prudence, few, per- haps, of the employments of men would be injuri- ous to health. , „ J. Darwall. 182 ASC sion augmented flow of blood to the brain, and consequent disease of that viscus, even in the adult. Still more likely is this to ensue, if the same application be made before the organs have undergone their full evolution ; and hence we may conceive that early and intense study may lay the foundation to faulty development in other parts of the frame, and to great energy of nutri- tion in the brain. But whilst it is admitted that such may be the case, it probably happens but rarely, far less frequently than is believed. (Dun- glison's Elements of Hygiene, p. 474. Philad. 1835.) Dr. Guy, in the Journal of the Statistical So- ciety of London, (cited in the Provincial Med. and Surg. Journal for Dec. 16, 1843 ; and in the Philadelphia Medical Examiner for March 9, 1844,) has entered at some length into an inqui- ry on the influence of employments upon health. It confirms the results arrived at by other observers, in showing the great advantage which the better classes enjoy over other members of society. They appear to have longer, and probably enjoy better, health. This is doubtless owing to bet- ter ventilation and food, and the greater atten- tion bestowed on the places which they inhabit. It is partly also due, as Dr. Guy has suggested, to the facilities which they enjoy for exercise in the open air. The great difference between the gentry and other members of society is not more worthy of notice than the slight advantage which the tradesman in Great Britain enjoys over the class of workingmen : according to Dr. Guy, if we limit the comparison to the average age, we find that the tradesman lives about three quarters of a year longer than the entire class of working- men—little more than a year and a half longer than the class employed solely within doors—two years longer than the men following the more sedentary occupations, and about three years longer than the class which consists chiefly of domestic servants. On the other hand, the life of the tradesman is shorter by about a quarter of a year than that of the entire class of out-door labourers. The little ad- vantage possessed by the tradesman over the mass of workingmen, Dr. Guy thinks, probably results from the sedentary life he leads, his want of pro- per exercise, and the small space which the neces- sities of business allow him to appropriate to the accommodation of himself and family. Taking one tradesman with another, it is, perhaps, not unreasonable to suppose that he habitually breathes an air as impure, and follows an occupation nearly as unwholesome, as the class beneath him. The labour which the workingman has to undergo, provided it is not carried to excess, is more favour- able to health than the confinement to which the tradesman is subject; and this confinement raises him in the scale of mortality but little above men following the more sedentary occupations. Both classes of men, the tradesman and the working- man, are doubtless exposed to unwholesome influ- ences, which might be wholly removed or greatly mitigated by the interference of others, or by their own precautions.] In closing this article, we cannot omit to notice that the different employments of life are rendered far more pernicious than they would otherwise be, ASCARIDES. See Worms. ASCITES. This term is employed to desig- nate abdominal dropsy, [dropsy of the peritoneum,] and is the same with the Greek word aoKtrns, which has been derived from &— re-establishment of respiration ; namely, that the very power to which it must owe the restoration of its irritability, by the propulsion of fresh arterial blood through the vessels, has, on this hypothesis, been itself destroyed, and therefore the means of recovering it do not exist. Resuscitation from asphyxia would, if this were true, be impossible. But since daily experience shows us that the heart may be made to renew its contractions even some time after they have ceased, we are forced to conclude that that organ still retains, under these circumstances, a considerable share of irritability, ready to be called into action, when a proper sti- mulus is applied. On the renewal of the action of the pulmonary capillaries, by which means a fresh supply of arterial blood is poured into the left auricle and ventricle, these cavities are urged by their appropriate stimulus, which is that of mechanical distension, again to contract and re- new the circulation. Arterial blood being thus again diffused over the system, imparts its vivify- ing influence to all the organs ; their suspended functions are resumed, and animation is restored. In confirmation of the views here given, we may cite the experiments of Dr. Kay,* and also those of Dr. Edwards,-)- which tend to prove that when venous blood is made to circulate through the substance of muscles, it contributes to support their irritability in a certain degree, although less effectually than arterial blood. Admitting, then, that the heart retains a certain portion of irrita- bility, sufficient to account for the renewal of its contractions under certain circumstances, it would appear that the causes of the cessation of its action may be resolved partly into a deficiency of supply of blood to the left ventricle, consequent upon the paralysis of the capillaries of the lungs, which de- prives them of the power of propelling it forwards; partly into its own diminished irritability, arising from the direct effect of the entrance of venous blood into the coronary arteries ; and partly also into the participation of the heart with the general deleterious impression made on the whole nervous system, by the circulation of venous blood in the brain and other parts of the system. So inti- mately are all the vital functions connected to- gether, that it is extremely difficult to assign to each of these causes the real share which it re- spectively has in the production of the whole of the observed effect. There can be little doubt that any one of them would of itself be sufficient to arrest the movements of the whole machine ; and that the derangement of any one of the func- tions which are here implicated, would necessarily throw all the rest into disorder, and destroy the equilibrium of the system. The first, in point of time, in the series of phenomena consequent upon the suspension of the arterializing process, is the affection of the brain. Were this the sole effect directly produced by the want of oxygen, or superabundance of carbon in the blood, then might asphyxia be ranged under the head of apoplexy ; and the subsequent failure of the circulation would be a consequence of the impaired energy of the nervous powers which maintain the energy * See Edinburgh Medical and Surgical Journal, vol. xxix. pp. 42 and 46, [and The Physiology, Pathology, and Treatment of Asphyxia. Lond. 1834.] t De llnfluence des Agens Physiques sur la Vie. Part i. cit. i. and part iv. ch, iv. 192 ASPH\ aia. of the heart. But this can scarcely be admitted to be the sole cause of death; because the motion of the heart in asphyxia is arrested much sooner than it ever is in simple apoplexy. We find, in- deed, that in the latter disease the heart continues to beat for many hours, or even days, after the destruction of the faculties of sensation and of consciousness; and it appears at length to stop principally in consequence of the cessation of t* breathing, which always takes place when the abolition of the powers of voluntary motion has proceeded a certain length. So that, in fact, it may more properly be said that apoplexy proves fatal by inducing a state of asphyxia, than that asphyxia is merely a species of apoplexy, as it has been erroneously classed in some systems of nosology. The chief seat of the stagnation of the blood in asphyxia is the minute pulmonary vessels; and this may be inferred from the fact that the whole of that part of the vascular system, and apparatus connected with it, which precedes it in the order of circulation, is distended with blood. Such, we have seen, is the condition in which the pul- monary arteries, the right ventricle and auricle of the heart, the venae cavae, and all their branches, are found after death. On the other hand, those portions of the vascular apparatus which follow this point in the order of circulation, are nearly empty of blood ; namely, the left auricle and ven- tricle, the aorta, and all its branches and rami- fications. The inquiry into the condition of the pulmonary capillary vessels, which this stagnation of the blood in them implies, would open a wide field of discussion; for it would involve the dis- puted question of the nature of the action of the capillaries, the power they possess to propel their contents, and the extent in which they contribute to carry on the circulation. Without entering into this discussion, for which this is not the pro- per place, it will be sufficient to state that, by the expression of paralysis of the capillaries of the lungs, we have merely meant to denote that con- dition which renders them incapable of transmit- ting onwards the blood which is sent to them. It might certainly be expected that, on the interrup- tion to the chemical changes which the blood usually undergoes in the lungs, these vessels would be the first to suffer from any noxious pro- perty which the blood might thereby acquire ; since they are more intimately in contact with it, and more extensively exposed to its action. While we admit, however, that this affection of the pul- monary capillaries is one of the principal causes of the cessation of the heart's action, it is at the same time very probable that the diminution of its energy, occasioned by the circulation of venous blood through its substance, contributes in a great degree to the same effect. It is of great import- ance, in a practical point of view, to obtain a true theory of asphyxia ; since the success of the mea- sures we may adopt for the purpose of restoring suspended animation will depend on its correct- ness. [Experiments have been since instituted, which do not accord in all respects with those of Dr. Kay. Dr. Reid concludes, that the suspension of the functions of the encephalon is chiefly, if not entirely dependent upon the circulation of venous blood in the arteries. He does not, however, maintain, that venous blood exerts any noxious influence upon the functions of the nervous texture, but believes, that the effects are solely attributable to the want of the proper excitation of the organ; for, when the circulation of arterial blood is re- newed, its functions rapidly manifest themselves, provided this be done within a given time. He believes, that the order of succession in which the vital processes are arrested in asphyxia is as fol- lows :—The venous blood is at first transmitted freely through the lungs, and reaches the left side of the heart, by which it is driven through all the textures of the body. As the blood becomes more venous, its circulation through the vessels of the brain deranges the sensorial functions, and rapidly suspends them, so that the individual becomes unconscious of all external impressions. The functions of the medulla oblongata are enfeebled about the same time that the sensorial functions are arrested, but are not fairly suspended for some time longer. Immediately after the sensorial functions are suspended, and the blood has become still more venous, it is transmitted with difficulty through the capillaries of the lungs, and, conse- quently, begins to collect in the right side of the heart. A smaller quantity of blood must now necessarily reach the left side of the heart; and the diminution of the quantity of blood sent along the arteries, conjoined with its venous character, and the ultimate arrest of the circulation, being sometimes incompatible with the manifestation of vitality in the other tissues of the body, general death is sooner or later induced. This view con- sequently ascribes the phenomena of asphyxia chiefly to the circulation of blood that has not been oxygenated in the lungs, or, in other words, of blood devoid of the proper excitant agency, and subsequently to arrest of the blood in the capilla- ries of the lungs, which occasions the flow of arte- rial blood towards the left heart to be arrested. As a consequence of the want of the stimulus of distension, the left cavities lose their contractility; —the right auricle, which continues for a time to receive blood by the venae cavae, being the ultimum moriens. The nervous, muscular, parenchyma- tous and other tissues, no longer receiving a sup- ply of arterial blood, cease, also, to act; but those organic functions, which are effected in the capil- laries of the general system, as nutrition, secre- tion and calorification, yield last; circulation con- tinuing in the capillaries for some time after it has ceased in the larger vessels.] PARTICULAR kinds or Asphtxia.—The first class of causes producing asphyxia we have stated to be the deficiency of oxygen in the air respired. These may again be divided into three heads. First, Excessive rarefaction of the air. Ani- mals have often, for the sake of experiment, been destroyed by being placed under the receiver of an air-pump; and if the process has not been too long continued, the mere re-admission of air is generally sufficient to restore life. The pheno- mena they exhibit under these circumstances do hot appear to differ, in any notable manner, from those which animals of the same kind present when suddenly plunged into an atmosphere of gas of the ordinary density containing no oxygen. With regard to the human body, the only way in ASPHYXIA. 193 which it is ever probable that death can arise from the excessive rarefaction of the atmosphere, is in the case of ascent to very elevated regions, as on the summits of mountains or in balloons. But, although the muscular strength is found to be much enfeebled under these circumstances, it ap- pears never to amount to a degree that is danger- ous to life. Secondly, The respiration of gases, which, although they contain no oxygen, appear of themselves to have no positively injurious opera- tion on the system. To this class belong hydro- gen and azotic gases. It is found, accordingly, that the voluntary endeavour to respire these gases for a short time is unattended with danger. This has been proved very satisfactorily by the experi- ments of Sir Humphry Davy, and many others. The deviations from this general result, which have been observed by some experimentalists, may readily be accounted for by impurities in the gas, and more particularly by the admixture of carbonic acid gas. In this way we may explain the obser- vation of Sir Humphry Davy, who reports that he experienced a greater sense of suffocation from respiring azotic than hydrogen gas. The pheno- mena exhibited by animals confined in either of these gases are those of simple asphyxia. Thirdly, The respiration of gases having posi- tively deleterious effects upon the system. To this head may be referred carbonic acid and car- buretted hydrogen gases, which produce no visible changes on the animal textures ; and also various other gases, which exert an immediate destructive chemical action on the parts with which they come in contact: of this latter kind are chlorine, sul- phureous, and nitric acid gases, ammoniacal gas, &c. Asphyxia from the respiration of car- bonic acid gas.—The instances of persons losing their lives from respiring air charged with carbonic acid gas, are very frequent The diffusion of this gas through a large mass of air is exhibited on a great scale in mines, where it is known by the name of the choke damp. From its greater specific gravity, compared with that of common air, it is always found in the lowest parts of the mine, and is on that account dislodged with great difficulty. In volcanic districts, streams of car- bonic acid are often known to issue in considera- ble quantities from fissures in rocks; a remark- able instance of which occurs in the celebrated Grotto del Cane, in the neighbourhood of Naples; being so named because dogs are kept near the spot, for the purpose of exhibiting to travellers the effects of this air upon these animals. Their beads are held in the gas, which only rises to a certain level in the grotto, till asphyxia is induced; from which state they generally soon recover, after being removed into pure air and plunged into water. The same gas is sometimes found to occupy the bottoms of wells or vaults; especially if they have been allowed to remain for a long time unopened. Large vessels, where the vinous fermentation has been carried on, such as brewers' vats, become often filled with carbonic acid, ren- dering it highly dangerous for persons to descend into them without having previously ascertained the respirability of the air they contain. This may always be done by letting down slowly a Vol. I. —25 a lighted candle. If the candle continues to burn, the air that surrounds it is capable of maintaining life ; and the place at which the candle goes out will show the height to which the foul air reaches. The vapour of burning charcoal, which is formed by the combination of its carbon with the oxygen of the atmosphere, consists chiefly of car- bonic acid gas, together with a certain small pro- portion of carburetted hydrogen, depending upon the presence of moisture in the charcoal. This vapour has often been the cause of suffocation to those who have been exposed to its influence. It has often happened that persons have gone to bed in a close room in which a charcoal fire was kept up through the whole of the night, and have been found dead in the morning. The same fatal effects have resulted from breathing the air of a lime-kiln, by persons who have approached too near; or who, having fallen asleep on the side of the kiln, have had the fumes which issued from it blown upon them in consequence of a change of wind. The effects of the respiration of carbonic acid gas are somewhat different according as it is in a concentrated or diluted state. If an attempt be made to breathe it in its pure or undiluted state, it is found to make so powerful an impression on the throat as immediately to excite a spasmodic con- traction of the glottis, which remains completely closed, so that no portion of the gas can be made to enter into the bronchi, in spite of every effort of volition. Sir Humphry Davy introduced into a silk bag four quarts of well-washed carbonic acid in a state of great purity, and after a complete voluntary exhaustion of his lungs attempted to inspire it. It communicated a strong acid taste to the mouth and fauces, and a sense of burning at the top of the uvula. It was in vain that he made the most powerful voluntary efforts to draw it into the trachea: at the moment that the epiglottis was raised a little, a painful stimulation was induced, so as to close it spasmodically over the glottis; and the same thing happened in repeated trials. (Re- searches concerning Nitrous Oxide, &c. p. 472.) A similar trial of the effects of breathing this gas had been long ago made by Pilatre de Rozier, (Journal de Physique, xxxviii. p. 418,) who, for the purpose, went into a brewer's tub while it was full of carbonic acid evolved by fermentation. His first sensation was increased heat and perspiration, attended with itching, especially in the eyes. Whenever he attempted to breathe, he was pre- vented by a violent feeling of suffocation. He sought for the steps to get out," but as he was doing so, the necessity for breathing increased, he became giddy, and felt a tingling sensation in his ears. As soon as his mouth reached the air he breathed freely, but for some time could not distinguish objects; his face was purple, his limbs were weak, and he understood with difficulty what was said to him. He soon recovered, however, from this state. This experiment was often repeated ; and he always found, that as long as he remained without attempting to draw his breath, he could move without inconvenience; but every attempt to breathe instantly brought on the feeling of suf- focation. Persons exposed by accident to the influence of an atmosphere of this kind seldom escape the 194 ASPHYXIA. * danger in which it places them. It is not uncom- mon, for example, to hear of a person descending into a brewer's vat or into a vault, containing a stratum of carbonic acid up to a certain height, and falling down in an instant, as if shot, without the slightest struggle. Another person going to his assistance, and, of course, warned by his exam- ple, prepares himself to resist the fatal influence of the gas; yet with every precaution he can take, and with every provision, for being pulled up by assistants by means of ropes, we will suppose, tied round him for that purpose, he also is seen sud- denly to drop, without his even being able to make the preconcerted signal. A third person descends and undergoes the same fate. It has thus often happened that several persons in succession have fallen victims to their humanity in endeavouring to rescue others from so perilous a situation. These facts seem to prove, in the most une- quivocal manner, the positively deleterious pro- perties of this gas, which produces a sudden abolition of all the animal functions, without even being applied to any considerable extent of the internal pulmonary surface. The immediate symptoms which it excites are, sensations referred to the head, pain, giddiness, a feeling of debility, which mark the strong impression that is made on the sensorium ; and the whole nervous system is doubtless in like manner powerfully affected. It has been alleged also that the muscles of animals destroyed by immersion in irrespirable gases, lose more of their irritability than happens with those which have been hanged or drowned. The symptoms produced by the continued respiration of carbonic acid gas mixed with atmo- spheric air, partake much of the character of apo- plexy. We may still observe that the primary effects appear to be produced upon the brain. Headach, vertigo, slight nausea, heaviness, and irresistible inclination to sleep, mark the first stages of this affection. The patient passes from sleep to coma, from which it is impossible to arouse him ; the pupils become dilated, the respi- ration stertorous. The countenance is flushed, the lips are livid ; the pulse is often full and strong. There is no gasping for breath, no painful struggle, no unutterable anxiety, no convulsion. The transition from life to death is calm and tran- quil, and the functions and powers of the system are one by one extinguished, as if in obedience to the resistless spell of some potent enchanter. Such was the mode of death chosen by the younger Berthollet when bent upon suicide. He shut himself up in a small closet by the side of a chafing-dish of burning charcoal, carefully closing every aperture through which the poisonous fumes could escape ; and quietly sate himself down to register the successive feelings as they arose. They were such as attend the operation of a nar- cotic. The description of them which he had written had evidently been interrupted by a pause; then followed an almost illegible word ; the pen must then have dropped from his hand ; he pro- bably never stirred afterwards. The particulars of two interesting cases of ex- posure to the vapour of burning charcoal, with the details of the treatment adopted, are given by Dr. Babington in the first volume of the Medico-Chi- rurgical Transactions (p. 83) ; and they are ren- dered highly instructive by the judicious reflections which accompany the narrative. He observes that the fatality of this gas to the different classes of animals is, in general, in proportion to the more complicated system of their organization. On the human constitution, according to the pe- riod of exposure, and the degree of concentration, its effects vary through all the shades of giddi- ness, pain of the head, anxiety, depression of the powers of life, impeded respiration, loss of volun- tary motion and sensation, to the complete sus- pension of respiration and circulation. The power of resistance to this narcotic agency appears to be less in youth than in a more mature age. The two persons above mentioned, the one a man thirty-eight years of age, and the other a boy of thirteen, had gone to bed in a room in which a chafing-dish of burning charcoal had been placed at the foot of the bedstead. In the morning the boy was found completely dead, having appa- rently gone off' without a struggle ; but the man was in an apoplectic state, and by the employment of proper means eventually recovered. A parallel case is related by Bourdon, (Principes de Physio- logic Medicale, partie ii. p. 650,) of a woman, thirty-five years of age, who, being reduced to a state of desperation by jealousy and misfortunes, had taken the resolution to destroy her own life together with that of her daughter, a girl of five years of age. Having shut herself up with her child in a closet with a large brasier of burning charcoal, the bodies were, some time after, found extended on the floor. The mother was recovered without much difficulty; but none of the means that were tried could elicit from the child the smallest sign of life. Asphyxia front carburetted hydrogen gas.—The respiration of carburetted hydrogen gas is peculiarly fatal to life, appearing to act as a ., direct sedative, immediately destroying the vital **" powers. A bold attempt was at one time made by Sir Humphry Davy to breathe this gas in its undiluted state : he took three inspirations, which very nearly killed him ; (see his Researches con- cerning Nitrous Oxide, p. 468.) Even when mixed with common air, it has a singularly de- pressing influence upon the powers of life. The extensive introduction of this gas, within these few years, for the purpose of lighting the streets and public buildings, is likely to lead to the fre- quent occurrence of accidents of this nature. Gases of a more compound nature, and still more deleterious properties, are often emitted in great abundance from putrefying animal and ve- getable substances, and especially from privies, sewers, and burying-grounds. A striking account of the remarkable effects produced by the exhala- tions from opening graves has been given by Four- croy. It appears, from the report of the grave-diggers who were examined on the occasion referred to, that those men who happened to be standing imme- diately over a corpse, of which the abdomen was suddenly struck into by a pickaxe, often fell down, on a sudden, in a state of apparent death ; while those who were at a greater distance, and received the noxious effluvia in a more diluted state, were attacked with nausea, giddiness, tremors, and faintness, which symptoms continued for some hours. tf ASPHYXIA. 195 Asphyxia from Drowning.—In our classi- fication of the causes of asphyxia, submersion or drowning forms the second head. The general account we have already given of the symptoms and progress of asphyxia in its simpler forms, supersedes the necessity of entering into a detail of all the phenomena attending as- phyxia from submersion, and it will only be requi- site to notice those that are peculiar to this mode of inducing the affection. The symptoms and appearances met with in drowning vary considerably, according to the state of the individual at the time of submersion, to his ability to make efforts to save himself, to accidents that may happen to him after falling into the wa- ter, to the depth and the temperature of the water, and other circumstances. Let us first take the simplest and most ordinary case of a healthy individual, in perfect possession of his faculties, falling into the water from a cer- tain height, and descending, from the impetus given by ,the fall, to some depth below the surface. He quickly rises again to the surface of the fluid, buoyed up by difference in specific gravity be- tween his body and the water, and also frequently receiving additional support from air entangled in bis clothes. If able to swim, he supports himself at the surface as long as his strength lasts him ; when that fails, he is in the situation of a person who is unable to swim; in either case he then performs movements at random with his arms and legs, and, while sinking to the bottom of the wa- ter, involuntarily grasps any object that comes within the reach of his hands. From the irregu- larity with which these actions are performed, he appears at the surface, and again disappears, seve- ral times successively. Whenever the mouth hap- pens to be out of the water a hasty gasp is made, by which water as well as air goes down the throat, and, exciting cough, is partly expelled from the trachea; but, by the same effort, the air that had been taken in at the same time is also rejected. This creates a fresh demand for air; and, as soon as an opportunity occurs, another and more hur- ried attempt is made to satisfy it. This very eager- ness tends but to defeat its own object; for if the head be only half raised above the surface, the chance is that water is again taken in by the effort to inspire. It is again rejected by the spasm of the glottis, and the consequent convulsive action of the muscles of the throat; and in \he painful conflict of the two contending elements some wa- ter is swallowed, and passes into the stomach. All these violent efforts tend to determine blood to the head; and that blood, partaking of the venous qualities, puts an immediate stop to the functions of the brain. Sensation and voluntary motion cease; the body sinks motionless to the bottom of the water, the pressure of which on the sides of the chest finally expels a portion of the air that still remained in*the lungs when the last effort was made. The account of these phenomena, given by Dr. Goodwyn, is so clear and concise that we shall give it in his own words :—" When an animal," says that author, (Connexion of Life with Respi- ration, p. 3,) " is immersed in water, his pulse be- comes weak and frequent; he feels an anxiety about his breast, and struggles to relieve it; in | these struggles he rises towards the surface of the water, and throws out a quantity of air from his lungs. After this, his anxiety increases : his pulse becomes weaker; the struggles are renewed with more violence ; he rises towards the surface again, throws out more air from his lungs, and makes several efforts to inspire; and in some of these efforts a quantity of water commonly passes into his mouth. His skin then becomes blue, particu- larly about the face and lips ; his pulse gradually ceases ; the sphincters are relaxed ; he falls down without sensation and without motion." The following is the account given by the same author of the appearances that present themselves if the body be immediately opened. 1. The external surface of the brain is of a darker colour than usual; but the vessels are not turgid with blood, nor are there any marks of ex- travasation about them. 2. The cavity of the lungs contains a consider- able quantity of frothy fluid ; and the pulmonary arteries and veins are filled with black blood throughout their whole extent. 3. The right auricle and ventricle of the heart are still contracting and dilating; the left sinus venosus and auricle move feebly ; but the left ven- tricle is at rest. 4. The right auricle and ventricle are filled with black blood, and the left sinus venosus and left auricle also; but the left ventricle is only about half filled with the same coloured blood. 5. The trunks and smaller branches of the arte- ries proceeding from the left ventricle also contain a quantity of this black blood. To this description we may add the following particulars. The face is in general pale, though slightly livid ; the mouth contains a good deal of frothy fluid ; the tongue is often protruded be- tween the teeth. The same frothy liquid is found in the trachea, bronchia, and air-cells of its lungs, as also some water, the quantity of which varies much in different instances. The lungs are of a violet hue, and the blood they contain is fluid, but less in quantity than in cases of asphyxia from carbonic acid gas. The left ventricle of the heart is never completely empty ; the quantity of blood found in it being generally about half that con- tained in the right ventricle, (Coleman on Sus- pended Respiration, p. 248.) Some blood is also found in the aorta. In the stomach there is al- most always found some portion of the fluid in which the person was drowned, and the quantity is sometimes considerable. The vessels of the brain do not exhibit any particular appearance of distension.* The air contained in the lungs has nearly lost the whole of its oxygen. This was the uniform result of a great number of experi- ments made by Dr. Berger, of Geneva, on the air that was expelled from the lungs a short time after immersion.-|- Great discordance exists in the representations ^x of different authors as to the quantity of water found in the lungs and stomach of drowned men and animals, and its influence on the destruction of life. De Haen was of opinion that death is * Observations on Apparent Death from Drowning, Slc. By James Curry, M. D. t Essai Physiologique sur la Cause de l'Asphyxie par Submersion. Par J. F. Berger, de Geneve, 1805. 196 ASPH YXIA. occasioned by water flowing into the lungs, and stopping the passage of the blood in the vessels. Dr. Cullen stated, from the result of many dis- sections, that there is often no water found in those situations; and never any quantity likely to in- jure the organization of these parts, (Letter to Lord Cathcart) Dr. Goodwyn's investigation of this subject is exceedingly satisfactory, and seems to have laid this question entirely at rest. By drowning animals in a coloured liquid, such as ink, he ascertained that the quantity of fluid that really entered the body was infinitely less than was adequate to produce death. He drowned other animals in quicksilver, which, from its not mixing with the animal fluids, could be more easily col- lected, and its quantity determined. He thus as- certained that only five drachms of the fluid in which a cat was immersed entered its lungs while drowning ; and in order to determine whether or not this could occasion the death of the animal, he made the following experiment: having con- fined a cat in an erect posture, he made a small opening in its trachea, and introduced through it two ounces of water into its lungs. The only effects it produced were a temporaiy difficulty of breathing and weak pulse ; but these symptoms soon subsided, and the animal lived several hours afterwards without experiencing any further in- convenience. At the end of this time it was stran- gled, and two ounces and a half of water were found in the lungs. Similar experiments were made with other fluids, and with nearly the same result. Hence Dr. Goodwyn concluded that, in drowning, a small quantity of water does usually pass into the lungs; that it enters during the efforts to inspire, and, mixing with the pulmonary mucus, forms a frothy fluid ; but that the whole of this fluid is insufficient to produce the changes that take place in drowning, (Connexion, &c, p. 19.) The experiments of Dr. Goodwyn on these points have been since confirmed by Mr. Kite and Mr. Coleman. Professor Meyer has also investi- gated the same question by employing water in which hydrocyanate of potash had been dissolved, and testing the fluid found in the lungs with the muriate of iron, (Medical Repository, vol. iii. New Series, p. 436.) We have hitherto supposed the person to retain his self-possession during the first moments of his finding himself in danger of drowning : but it may happen that he was intoxicated at the time he fell into the water ; or else the sudden impres- sion of cold, or the surprise and shock may have overpowered his faculties, and may have occasion- ed immediate syncope. It may also happen that in the fall his head has struck against some hard body, and he may be stunned by the blow. In all these cases, there is no struggle whatever; the body at once sinks passively to the bottom, never more to rise. Here it is evident that all the effects already described as the result of a struggle will not take place ; and the only appearances observ- ed after death will be those of simple asphyxia. Paleness will be seen in the face as well as in the rest of the body ; the trachea will merely contain a little water, but no froth ; the lungs will be but little distended, and will preserve their natural colour; and there will be no great inequality in the comparative quantities of blood contained in the arteries and the veins; and no fluid will be found in the stomach, but what was contained in it at the time of submersion. We may also suppose other instances in which this sudden syncope, or abolition of the cerebral faculties, may occur after a momentary struggle \ in which cases the phenomena already described will have been in part produced, and the further changes prevented from taking place. All these considerations are of great importance in their relation to many questions of medical jurispru- dence. The great diversity that may take place in these and other circumstances will enable us, perhaps, to explain the differences that are met with in the time during which the body may remain under water, compatibly with the possibility of restoring life. If the submersion have not exceeded five f* minutes, and no blow against a stone, or other violence has occurred to complicate the effects, our efforts at resuscitation, if properly conducted, will generally be successful. After a quarter of an hour, recovery is not very common ; after twenty minutes, or half an hour, it may be considered as hopeless. The longest period recorded in the Re- ports of the Humane Society is three quarters of an hour. On the other hand, some, who have only been a few minutes under water, cannot be restored to life even by the prompt application of the proper means. It appears from the first report of the establish- ment for the recovery of drowned persons at Pa- ris, that out of twenty-three cases restored to life, one had been three quarters of an hour under water, four had been half an hour, and three a quarter of an hour; the rest being for a much shorter time.* The habit of being under water, as in the case of professed divers, may enable a person to remain in that situation longer than he otherwise would be able to do; but its power will not go far. The Indian divers employed in the pearl-fishery are said to be capable of remaining three, four, and in some cases even five minutes without injury. (See Percival's History of Ceylon.) The numerous cases on record in which it is alleged that life has been restored after being several hours under water are totally unworthy of credit Asphyxia from strangulation.—The third division of the causes of asphyxia comprehends all those that prevent the access of air to the lungs, whether by suffocation or strangulation. The most common of these is a ligature round the neck, as in the case of hanging. Considerable variety is observed in the length of time during which vitality continues while criminals are suspended from the gallows; the differences depending, in a great measure, on the mode in which the rope is adjusted round the neck, the height and suddenness of the fall, and other circumstances of violence attending the exe- cution. Much also will depend on the peculiar constitution and previous bodily condition of the individual. Convulsions of an epileptic character very generally supervene on the loss of sensibility, which, if the closing of the trachea be complete, as * Detail des succes de l'etablissement que la Ville de .Hi8 a faite en fsveur des personnes uoytts. Paris, 1773, quoted by Dr. Good. ASPHYXIA. 197 it generally is in consequence of the strong pres- sure of the rope, very speedily follows the exclu- sion of air. The face is always turgid, and suf- fused with livid blood. This swelling and tur- gescence extend also to the shoulders, arms, hands, and chest, which are of a livid hue. The eyes are generally open, and projecting, and the vessels of the conjunctiva distended with blood. The tongue is frequently thrust out of the mouth, and wounded by the convulsive action of the jaws; and a bloody mucus issues, in consequence, from the mouth. The distortion of the features, and 6ther marks of strong muscular action, are evidently conse- quences of the violent struggles of the sufferer, and are proportional to the irritation excited in the brain. The muscles which raise the shoulders, and assist the muscles of inspiration, are strongly contracted. The other muscles of voluntary mo- tion, instead of being rigid, are more relaxed than usual; so that the limbs exhibit more flaccidity than in cases of tranquil death. The mark of the cord will always be evident round the neck, form- ing, when the person has been hanged up alive, a livid depressed circle. Frequently we find patches of ecchymosis on the surface of the upper part of the trunk and superior extremities. The fingers are bent, the nails blue, and the hands firmly clenched. From the relaxation of the sphincters, the urine and faeces are often involuntarily expelled. Erection of the penis and emission of semen also frequently take place from hanging. It is evident, from all these circumstances, that the struggle is usually more intense in this mode of death than in drowning. This happens more especially when, from the inaccurate adjustment of the rope, from rigidity of the cartilages of the larynx, or from any other cause, the trachea is imperfectly closed : for, in that case, a small cur- rent of air may still pass, and, though insufficient to support life, may contribute to prolong the sufferings and struggles of the victim. This is often observed in those who voluntarily hang themselves, and who frequently suffer much be- fore they die, in consequence of their inexpert mode of executing their purpose; and in whom we consequently find the cheeks, lips, eyes, and tongue particularly swollen and prominent. In the same proportion as we meet with these indi- cations of a more protracted death, we find the lungs less gorged with blood, and the blood about the heart more equally distributed among its cavi- ties and great vessels. For, in consequence of the admission of even a small portion of air into the lungs, the heart is enabled to keep up the circula- tion for a longer time, and is only more gradually overpowered ; while, at the same time, the pres- sure of the rope on the jugular veins in the neck obstructs the return of the blood from the head, accumulates it in the vessels of the face, and gives rise to the appearances of apoplexy. But wherever the obstruction of the trachea has been complete, there is no evidence that death by hanging is the consequence of apoplexy : and, in fact, when the executioner is sufficiently expert in his task, death is too suddenly induced to admit of an accumulation of blood sufficient for producing apoplexy. De Haen ascertained, from numerous experiments on dogs, which he hanged and opened •a • as soon as they were dead, that no marks of apo- plexy were to be found in the brain. The following experiment, performed many years ago by Dr. Monro, Senior, of Edinburgh, proves incontestahly that the immediate cause of death in hanging is the exclusion of air from the lungs. A dog was suspended by the neck with a cord, an opening having previously been made in the trachea below the place where the cord was applied, so that air could pass into the lungs as freely as in ordinary respiration. After hanging in this state for three quarters of an hour, during which time the circulation and the breathing went on as usual, he was taken down, and appeared not to have suffered materially from the operation. The cord was then shifted from above to below the opening made into the trachea, so as totally to prevent the ingress of air into the lungs; and the animal being again suspended, was in a few minutes completely dead. (Curry, Observations, &c. p. 71.) It is very probable, however, that the degree of obstruction to the circulation occasioned by a tight ligature on the neck, which presses upon the jugular veins, has a considerable share in hasten- ing the period at which death would take place were it dependent on the mere interruption to breathing : so that, from this double cause, the punishment by hanging, if dexterously executed, is probably unattended with much pain. By the violent means often employed in the execution of criminals in this country, it may, indeed, happen that another and more suddenly fatal injury is produced, namely a dislocation or fracture of the cervical vertebrae. We have reason to believe, however, upon good authority, that such accidents are rare, even when on a public scaffold a hardened criminal leaps from the gallows to obtain a quick termination to life ; and it can hardly ever occur in cases of suicide. It is evident that, were any fracture or luxation of the vertebrae of the neck to take place, immediate death would ensue, and would preclude all possibility of recovery, however promptly assistance might be afterwards afforded; whereas instances have been recorded of victims to the law having been recovered by inflating the lungs after the body had been cut down. Dr. Plott, in his Natural History of Stafford- shire, (page 292,) relates that in the reign of Henry VI. a woman of the name of Snetta de Balsham, after having been hanged according to the sentence of the law, and cut down after being suspended a whole night, was found to be still alive; in consequence of which extraordinary escape she was pardoned by the king. But it appears, from Dr. Plott's account, that she owed her preservation to an ossification of the larynx, which kept open a passage for the air. Attempts have often been made to defeat the object of the punishment by introducing a silver canula into the trachea, previous to the execution; but the intolerable irritation excited in so sensible a part as the glottis by the presence of an extraneous body, must ever preclude all hope of success from such a project. If the method practised in Dr. Monro's experiment on a dog, were adopted in the case of a person intended for execution, it might certainly be attended with a successful result. It 198 ASPHYXIA. is recorded, indeed, that an expedient of this kind was actually tried in a remarkable case, the par- ticulars of which are given by Dr. Mahon. (Me- decine Legale et Police Medicale, torn. iii. p. 62.) A butcher, of the name of Gordon, was condemned to execution, at the Old Bailey, for highway robbery, in the beginning of the last century. Having amassed great riches by his successful career of crime, he persuaded a young surgeon, by the hope of a great reward, to attempt to save his life. The surgeon proposed the plan of making an opening low down in the trachea, and introducing through it a small canula. This was secretly accomplished previous to the execution ; the blood that was effused in consequence excited some suspicion, but being attributed to a desperate attempt at suicide, the circumstance only occa- sioned the hastening of the hour of his execution. After the body had hung the usual time, it was taken down, consigned to the relations, and quickly removed to a neighbouring house, where the sur- geon was anxiously waiting to receive it. He immediately drew some blood from the jugular vein, and enforced every means calculated to restore animation. Gordon opened his eyes, heaved a deep sigh, but expired a few minutes after. The failure of success was attributed to the great weight of the body, which increased the violence done to the parts compressed by the rope. The appearances presented on opening the bodies of persons who have been hanged, besides the local marks from the pressure of the cord, are exceedingly similar to those produced by drown- ing, and of which we have already given a suffi- ciently detailed account. The right cavities of the heart, and the pulmonary vessels, are full of blood ; the left cavities and the arteries very nearly empty. The principal difference, however, is in the state of the lungs, which are found remarkably distended with air, so that they do not readily collapse when the thorax is opened. There is, of course, no water found in the bronchia or air- cells, as often happens after submersion. Dr. Goodwyn ascertained that the lungs of two per- sons of ordinary stature, who had died from hang- ing, contained in the one case two hundred and fifty, and in the other two hundred and sixty-two cubic inches of air; whereas the lungs of those who die a natural death contained only from ninety to one hundred and twenty-five cubic inches, (Goodwyn, Connexion, &c. sect iii. p. 25, 26,) or, taking the mean of four experiments, one hundred and nine cubic inches. The reason of this difference is obvious : persons about to be hanged are under the influence of fear, and will therefore naturally make a deep inspiration before the cord is tightened on the neck ; and the pres- sure of the cord on the trachea, when the body is suspended, becomes immediately so great, that the air cannot again be expelled. The absence of this obstruction in the case of persons who are suffo- cated in other ways, such as by the application of a pillow to the face, will account for the difference in this respect in the appearances after death. These appearances, when death has been produced under the circumstances just alluded to, approach more nearly to those of simple asphyxia, with the addition, however, of traces of the violence that has been done to the victim in the completion of the murderous design. It is possible, for example, that the murdered victim may have been first strangled, and afterwards suspended. If, there- fore, we should perceive, on a person found hang. ing, that there are two distinct circles formed by a cord; or deep impressions of fingers on the throat; and if, at the same time, the clothes are torn, the hair dishevelled, or other indications of resistance are observed, we may fairly presume that violence has been committed by another, and that it is not a case of suicide. All indications of this kind become the subject of serious investi- gation in any legal inquiry implicating the guilt of parties accused of such crime; but as they con- stitute an important topic of medical jurisprudence, we shall pass them over as being foreign to the purpose of this article. Among the causes which induce asphyxia may be enumerated the introduction of foreign bodies into the larynx or trachea ; such accidents are not unfrequent, and produce various degrees of im- pediment to respiration, according to the bulk, shape, and situation of the extraneous body. Even if they do not immediately prevent the ingress of air, they excite by their presence such violent irri- tation and spasmodic action, as are soon followed by a high degree of active inflammation, which, producing a swelling of the membranes, contri- butes still further to contract the passage, and in- duce asphyxia. The nature and succession of the symptoms will, of course, be very similar to those of strangulation; but the sufferings are more protracted, the anguish is extreme, and the extinction of the powers of life more gradual. A person may even live for some days, if the trachea be only partially obstructed : if the obstruction is complete, he loses all sensation in a few minutes, and soon after expires. The Greek poet Anacreon is said to have lost his life in the eighty-fifth year of his age, from a grape-stone which stuck in his throat while luxuriously quaffing some new wine. Suffocation sometimes follows the bursting of an abscess which has been formed in the tonsils, and suddenly poured its contents into the larynx. Croup occasionally proves fatal by the mechanical obstruction which is created by the adventitious membrane that is formed in that disease. Asphyxia is sometimes the result of pressure applied to the body in so general a manner as to impede not only the motion of the ribs, but also that of the diaphragm. This will happen, for example, to a miner, buried completely under a mass of earth that has fallen upon him. Death will in that case be induced with greater rapidity than from most other causes of asphyxia ; because the pressure will force out nearly the whole of the air contained in the chest, and preclude any further movement of dilatation or contraction1 of its sides. The circulation is quickly arrested, and no oppor- tunity is afforded for the accumulation of blood in the venous system. The body, accordingly, will present no discoloration of the skin, no turgescence of the veins, no engorgement of the pulmonary vessels. We have here, it is true, represented what will happen in an extreme case. Modifica- tions will obviously arise, corresponding to the peculiarity of circumstances existing in each par- ticular instance, and into the detail of which the exposition of these general principles renders it ASPHYXIA. 199 unnecessary to enter. We shall mention only one remarkable instance, in which a person was in great danger of losing his life from inattention to the physiological conditions requisite for respira- tion. An athletic black, of pugilistic celebrity, had been selected, from the fine form of his chest, and well-marked expiession of his muscles, as an academic model. It was wished to obtain a cast of his body; but this being attempted at one operation, and in one entire piece, as soon as the plaster began to set, he felt on a sudden deprived of the power of respiration, and, to add to his misfortune, was cut off from the means of express- ing his distress. His situation, however, was for- tunately perceived just in time to save his life, by breaking his bonds and releasing him from the extreme peril in which they had placed him. The consideration of the effects of the admis- sion of air, or of collections of fluid in the thoracic cavities compressing the lungs, as also the conse- quences of injuries to the spine above the origin of the phrenic nerves, or a paralysis of those nerves from any other cause, in producing asphyxia, will fall more properly under other heads. General treatment of Asphyxia___Although the suspension of all the vital actions of the system which takes place in asphyxia has originated from ZTthe temporary interruption in a single function, yet the derangement which has followed is of so complicated a nature, and extends to so great a number of important organs, that the mere re- establishment of the function primarily disturbed is not immediately followed by the restoration of the rest, and by the removal of all the mischief that has been created. The mere introduction of fresh air into the lungs cannot at once restore the action of the heart, and still less that of the dia- phragm, and the other muscles which are con- cerned in respiration, because these muscles have lost either the whole or the greater part of their irritability, in consequence of their having been supplied with venous instead of arterial blood. While our first and principal object is to bring the blood contained in the pulmonary vessels under the influence of atmospheric air, attention must at the same time be paid to the state of the circula- tion, and to the restoration of those powers by which that function, as well as respiration, is to be carried on. This double object should con- stantly be kept in view in all our attempts at resuscitation. The first of these objects can be accomplished only by the artificial inflation of the lungs, and this should be done with as little delay as possible. The second object is to be attempted by the judi- cious application of stimulants applied to various parts of the body, so as indirectly to eveite the powers of the nerves and muscles. Warmth, friction, and electricity are among the most effica- cious of these means. The particular mode of their application will depend upon the peculiar circumstances of each individual case, and will come more properly to be considered when we treat specifically of each kind of asphyxia. But as the most important points in the management are common to all cases, we shall proceed to con- sider them in this place, as properly belonging to the general view we are now takin.tr of the subject. Valuable directions as to the most effectual methods for recovering persons under asphyxia have been collected and published by the Royal Humane So- ciety ; of these we shall give an abstract, together with such additions as have been suggested and recommended by various authorities. It should be borne in mind that in all cases of asphyxia, the first and principal measure to be adopted is the employment of artificial respira- tion ; but if we have not the means of putting this into execution, the next measure, in point of im- portance, if the body be cold, as it generally is, is the application of warmth, which should be re- sorted to without loss of time : and, as it can be done without interfering with the process of in- flating the lungs, both methods may be employed simultaneously. Several preparatory steps should be taken before beginning the process for resuscitation. The body should be stripped of its clothing, and wrapped in warm blankets. It should be placed on its back on a table, with the head, shoulders, and chest somewhat raised; and supported in that position. The windows and door of the room should be kept open in order to obtain as free a circulation of pure air as possible ; and for the same reason no more persons should be admitted into the room than are absolutely necessary. Bottles of hot water should be laid below the feet, in the joints of the knees, and under the arm-pits, if any cold- ness is perceived in these parts. Warmth is par- ticularly efficacious in restoring the circulation when it is applied to the region of the stomach. Immersing the body in a warm bath has been also recommended, and may in many cases be advan- tageous. Great caution, however, is to be exer- cised in the employment of this, as well as of other modes of suddenly imparting considerable heat. The degree in which it should be applied so as to contribute most to the patient's recovery will, indeed, depend upon a variety of circum- stances which should be duly weighed. It is well known that during the healthy state of the system, while the circulation is vigorous, the temperature of the body may be raised many degrees above the natural standard without, injury to the powers of life; but it appears, on the other hand, from the results of experiments on hybernating animals, that when the circulation of the blood has ceased, and the temperature of the body has been very considerably reduced, if heat be then applied either very suddenly or in a high degree, life is soon destroyed : whereas, if it be applied to the same animals gradually, and in a very low degree, the vital powers are excited into action, and the func- tions are soon restored. Since the condition of the body in asphyxia, as Dr. Goodwyn remarks, (Connexion of Life with Respiration, p. 110,) is very analogous to the state of torpor which pre- vails in these animals, and since the progression of recovery is also the same, it is not unreasonable to conclude that heat will produce the same effects on the body in this disease as in torpid animals. To favour the recovery, then, most effectually, the application of heat should be conducted on the same plan that nature has pointed out in the awakening of hybernating animals from their state of torpor ; that is, it should be applied very gradually and uniformly. Accordingly it may , be raised to 98°, but not beyond 100°. 200 ASPHYXIA. Nothing, however, should divert our attention from the means on which we are principally to found our hope of success, namely, the extensive application of fresh air to the pulmonary vessels. There are several ways in which this may be attempted. The first and simplest mode is to endeavour to imitate as much as possible the movements in natural respiration, by first apply- ing pressure to the chest and abdomen so as to compress the lungs, and expel a great part of the carbonised air which they must necessarily con- tain ; then removing that pressure, so as to allow the lungs and the sides of the chest to recover their former dimensions by their natural elasticity. In so doing they will necessarily draw in fresh air through the trachea. By repeating this double operation at short intervals, so as to imitate the natural periods of inspiration and expiration, we may give the patient a chance of recovery by de- termining the commencement of circulation, at that critical time when the vital powers are quick- ly fleeting away, and every moment is of the ut- most consequence. But these attempts to supply the moving powers of the chest are always imper- fect, and can at best be considered as only auxi- liary to more efficacious methods. Still, however, they may be practised when no better assistance can be procured, or in the intervals of other pro- cesses. The object being to introduce pure air into the inmost recesses of the air cells, so as to exert a chemical action upon the blood in the pulmonary vessels, some degree of force must be used in order to overcome the mechanical obstacles to its ad- mission. For this purpose a considerable quantity of air should be introduced at each inflation; for, as Dr. Goodwyn observes, if only twelve cubic inches be injected at a time, this small quantity will occupy the larger branches of the trachea, and consequently only a small number of the pul- monary vessels will be exposed to its action : but if a much greater quantity of air be forced in at each time, some of it will pass into all the more remote cells ; and when they are thus uniformly distended, the pulmonary veins, the sinus veno- sus, and left auricle, will be exposed as much as possible to its action, and some of the arterialized blood may be forced into them from the capillary vessels. Hence Dr. Goodwyn recommends that upwards of a hundred cubic inches of air should be introduced into the lungs of an adult at each inflation, and carefully drawn out again before more is introduced. In situations where no proper apparatus is at hand, air should be blown with force into the lungs by applying the mouth of the operator to that of the patient, closing his nostrils with one hand, and gently expelling the air again by press- ing the chest with the other, so as to imitate the strong breathing of a healthy person. If any dif- ficulty be found in inflating the lungs in this way, it may be attempted by blowing through one of the nostrils, keeping at the same time the other closed. This operation is much facilitated by interposing a short wooden pipe, of a size adapted to the nostril, into which it is to be in- serted at one end, while the other is applied to the mouth of the person who is to blow through it The same tube will also be useful for receiv- ing the pipe of a pair of bellows, when this instru- ment can be procured. The blowing of air into the lungs of the patient from the mouth of a person, who must necessarily have breathed that air, and therefore vitiated it, has been objected to as being inconsistent with the very purpose we are aiming at, namely, the supply of pure and uncontaminated air to the pul- monary cells. On the other hand it has been thought preferable, from its introducing the air at a higher temperature than that of the atmosphere ; but it is certainly of much greater importance that . the air which is sent into the lungs should con- tain its full proportion of oxygen than that it be of the temperature of the body. Wherever, there- fore, a bellows, or other apparatus for the artificial inflation of the lungs can be procured, we should not hesitate to employ it immediately, in prefer- ence to any other method. The only instrument absolutely requisite for the performance of this operation is a common bellows : but the services of an assistant will be required in every case. The pipe of the bellows being inserted into the nostrils of the patient, the assistant must close the mouth and the opposite nostril, and at the same time gently press back the trachea, directing it also a little downwards, by pressing his finger upon the most prominent part of the larynx, commonly called the pomum Adami, or Adam's apple. The bellows is then to be opened, and immediately afterwards closed, so as to force air into the lungs. Its action is now to be stopped ; the nostril that had been closed should be allowed to open, and the lungs made to collapse by pressing down the chest, so as to expel the air as completely as possible. These actions should be repeated about fifteen times in a minute, so as to imitate the natural movements which take place in respiration. The process of inflating the lungs may be per- formed somewhat more readily and more com- pletely with instruments constructed for this ex- press purpose. The bellows employed with this view by the Royal Humane Society differs in no respect from an ordinary bellows, only that it is more accurately made, and is provided with a short flexible tube, one end of which fits on to the nozzle of the bellows, and the other is inserted into a silver tube, which is to be introduced into the nostril. In the Report of the Humane Society it is stated that, as the trachea is always open through the glottis, air conveyed through the mouth, the nostrils being closed, would necessarily pass into the lungs. If the cartilage of the larynx be pressed against the vertebrae, which it ought always to be, so as to close the oesophagus, and prevent the passage of the air into the stomach, and at the same time the mouth and left nostril be closed, and the pipe of the bellows inserted into the right nostril, the air must necessarily pass into the lungs through the trachea, this being the only opening through which it can find its way. Dr. Curry, in his •' Observations on Apparent Death," (p. 48,) gives the following excellent directions for conducting this process :— " While an assistant sustains the box-wood tube (into which a common pair of bellows can be made, by the assistance of a strip of linen, riband, ASPHYXIA. 201 or tape, to fit accurately) in one nostril, and stops the other nostril with his left hand, and with his right hand accurately closes the mouth, an- other assistant (who ought to be placed on the opposite or left hand of the body) is, with his right hand, to press backwards, and draw gently downwards towards the chest the upper end of the wind-pipe, that part which lies a little below the chin, and which, from its prominence in men, is vulgarly called Adam's apple,- by doing this, the gullet, or passage into the stomach, will be completely stopped up, whilst the wind-pipe will be rendered more open to let the air pass freely into the lungs. The left hand of this second as- sistant is to be spread lightly over the pit of the stomach, ready to compress'the chest and expel the air again, as soon as the lungs have been mode- rately filled ; the first assistant unstopping the mouth or nostril at the same time, to let the air escape. The same operation is to be repeated, in a regular and steady manner, either until natural respiration begins, or until this and the other measures recommended have been persisted in for at least six hours, without any appearance of re- turning life." It has been proposed to inflate the lungs with oxygen gas instead of atmospheric air ; and it is exceedingly probable that if a supply of that gas were immediately at hand, together with every facility in the way of apparatus for administering it, its efficacy, in restoring animation, would be superior to that of common air. But the cases must be exceedingly rare in which we can command these means, and, whenever they are not in com- plete readiness, it would be very wrong to lose any time in waiting till we can obtain them. We are not aware, indeed, of any set of experiments having been instituted for the express purpose of ascertaining the superiority of oxygen gas over common air as a means of resuscitation in as- phyxia, except those of Dr. Goodwyn, who merely says that he has employed oxygen gas in several instances in the smaller animals, and that the recovery was commonly more expeditious than where atmospheric air was used : but at the same time he acknowledges that he had never been able to recover an animal by means of oxygen gas where good atmospheric air had been inef- fectual. As a last resource, when the ordinary methods of inflating the lungs have entirely failed of suc- cess, and more especially if there be reason to presume that the chief source of difficulty arises from obstructions in the larynx and trachea, the operation of bronchotomy may be resorted to; which will allow of the forcible and more perfect inflation of the lungs by means of a pipe intro- duced into the opening made in the trachea. But it is only under particular circumstances that we need resort to this expedient. Various kinds of apparatus, some of a very com- plicated description, have been, at different times, proposed to be employed for the purpose of effect- ing the complete inflation of the lungs. But, in general, more is lost than gained by resorting to complex mechanical contrivances, which are often out of order at the very moment when they are wanted, and which always require time for their adjustment, and practical skill in their manage- , Vol. I___26 ment. The simple instrument we have described, namely, the common bellows, with a pipe adjusted to its nozzle, will be found sufficient to answer every practical purpose ; and even the latter may be easily dispensed with, if the pipe of the bellows be accurately applied to the nostril of the patient. By the introduction of a catheter into the trachea, if such an instrument be at hand, the lungs may be very conveniently and effectually inflated by blowing air through the tube. [In recent times, it has been shown, that the apparently simple operation of inflating the lungs is not as devoid of danger as was for a long time imagined; and it has been attempted to prove, that many cases may have resulted fatally from the violence of the insufflation, and consequent lesion of the pulmonary structure. To prevent these results, M. Leroy d'Etiolles recommends, that a graduated arc of a circle should be adapted to the handles of the bellows. One end of this arc is attached to one handle, whilst the other passes through a mortise hole in the other handle. The extent to which the handles are separated is measured by the graduated arc, and thus the quantity of air sent into the lungs may be deter- mined. With this bellows M. Leroy measured the quantity of air expired, without effort, into a bladder, by persons of different ages, and marked upon the arc of the circle the point to which the handle of the bellows was raised in each. He also had curved silver tubes, to be introduced into the glottis, made of different calibres according to the age, so as to render it impracticable to intro- duce the proper quantity of air, as indicated on the arc of the bellows, more rapidly than would be inspired at that age. This apparatus is simple, and its adoption has been properly and strongly advised, on the ground, that verbal directions often fail to impress the mind with a due sense of the dangers attending insufflation, especially when it has to be performed in such excitement and confusion as cannot fail occasionally to dimi- nish the caution even of experienced persons. In most of the cases of asphyxia, however, that occur, no such apparatus is at hand; and the operator is, consequently, constrained to make use of those agents that present themselves. These should of course be employed with the greatest precaution to prevent the evils that have been depicted by Leroy.] Gentle friction of the body with a warm hand may, at the same time that we are proceeding with the inflation of the lungs, be employed at first as a means of increasing warmth, and subse- quently, with a view of promoting the circulation of the blood. But the importance of friction, even as an auxiliary means of restoring life, has, we think, been much overrated. The application of stimulants of various kinds has been recommended with the same intention of exciting the action of the heart and of the muscles of respiration. We should be exceed- ingly cautious, however, in the employment of these means, and should in general confine our- selves to those that are external. In the instruc- tions for the recovery of drowned persons given by the Humane Society, it is stated that irritation applied to the nostrils has considerable influence in calling into action the muscles of respiration ; 202 ASPH1 A1A. and for this purpose it is recommended that the nostrils be occasionally touched with a feather dipped in spirits of hartshorn, aromatic spirit of vinegar, &c. With regard to applications of sti- mulants to the skin, they observe, that during life the skin loses sensibility in proportion as it is deprived of heat, and does not recover it again until the natural decree of warmth is restored. Hence it may be inferred that, before this heat has been recovered, all stimulating applications are useless, and, as far as they interfere with the other measures, must be positively prejudicial. When, however, the skin has in some degree recovered its sensibility, spirit of hartshorn, or eau de luce, closely applied, or a liniment composed of equal parts of spirit of hartshorn and salad oil, may be rubbed on the wrists, ankles, temples, and parts opposite to the stomach and heart It has also been recommended to introduce warm and stimulating fluids into the stomach by means of a syringe and flexible tube, such as that generally attached to the stomach-pump; for until the power of swallowing is pretty well re- stored, it would be dangerous to attempt getting fluids down the throat in any other way. Half a pint of warm negus, or water with spirits of harts- horn, mustard, or essence of peppermint, may thus be given. The best time for administering a stimulating cordial of this kind is a few minutes after the process of inflation is begun. A clyster of a pint or more of water moderately warmed, with the addition of the materials before men- tioned, or of rum, brandy, or gin, may be admi- nistered. Such, at least, is the advice given by the Humane Society, in cases of drowning, which may be considered as on the whole judicious, pro- vided proper caution be used in not going beyond them. Mr. Hunter certainly went much too far when he recommended the application of stimu- lating vapours to the interior of the lungs. (Obser- vations on the Animal Economy, p. 136.) For- tunately for the patient, as Dr. Bostock remarks, the natural actions of the organs are commonly sufficient to exclude the vapours ; for, were they admitted in any considerable quantity, suffocation would be the consequence. The only use of stimulating vapours, is to excite the nerves of the nose, which, by their connexion with the respira- tory nerves generally, may eventually stimulate the diaphragm to contraction. Not contented with the forcible injection into the stomach of stimu- lating liquids, some have advised the introduction of a piece of sponge impregnated with them, and fixed to the end of a small rod of whalebone, in order that the sides of the stomach may be, as it were, mopped round by the sponge thus charged, and stimulated in every direction. (Good's Study of Medicine, vol. iii. p. 562.) In the Ber- lin Transactions we find a recommendation of the use of a ventriculi executia, or stomach-brush, to produce internal friction in the same manner. Dr. Good, however, prefers the stomach-mop. It is hardly necessary to caution the reader against the adoption of these extravagant proposals. Neither can we approve of the recommendation of the in- ternal use of phosphorus, also recommended by Dr. Good, on the authority of some German phy- sicians, as one of the mosf powerful stimulants yet known. Various other expedients have been suggested, as means of assisting recovery, which are not merely of dubious utility, but should be repro- bated as exceedingly dangerous, and likely to frus- trate the very object we have in view. To this head may be referred emetics, which should never be given; and also tobacco clysters, either in the form of smoke or infusion, the tendency of which is to destroy instead of increasing the irritability of the system. ~f Slight shocks of electricity, or of galvanism, transmitted through the diaphragm or heart, may possibly be used with considerable advantage in many cases; for this agent has the power of ex- citing the contraction of a muscle which can be no longer acted upon by any other means. The galvanic apparatus being very portable, and not affected by the state of the atmosphere, it seems to be preferable, in cases of asphyxia, to the ordi- nary forms of electricity. It is easily applied, and its force can be exactly regulated by the number of plates we may employ. [A new method of application has been sug- gested by M. Leroy d'Etiolles. (Magendie's Jour- nal de Physiologie, torn, vii., viii., and ix., and Recherches experimentales sur VAsphyxie, Paris, 1829.) He introduced an acupuncture needle on each side, between the 8th and 9th ribs, until the needles reached the fibres of the diaphragm. He then established a galvanic current between these by means of a pile of 25 or 30 pairs of plates an inch in diameter. The diaphragm immediately contracted, and an inspiration was made. He now interrupted the circle, when the diaphragm, urged by the weight of the abdominal viscera, and aided by gentle pressure made on the abdomen with the hand, returned to its former position, and an expiration was accomplished. In this way, the two respiratory acts were made to succeed each other, and regular respiration was re-induced. A continuous current was likewise applied in some cases, but the respiratory movements were irregu- lar, and nothing like natural respiration resulted. Leroy tried his method on animals asphyxied by submersion, and when they had not been under water more than five minutes, they were often re- suscitated. On different occasions, he asphyxied animals of the same species, and apparently of like strength, and whilst those that were left to themselves perished, those that were treated by galvanism recovered. A case has been published in which the galvanic influence from a battery of fifty plates was applied immediately to the dia- phragm through an incision made below the sev- enth rib. The muscles of the chest and abdomen were instantly thrown into spasmodic action, which subsided in a few minutes into the regular move- ments of respiration. The man had been six or seven minutes under water. (Art. Asphyxia, in Cyclopedia of Practical Medicine and Surgery, ty. vol. 2, Philad. 1836 ; and Dunglison's Practice of Medicine, 2d edit, p. 421, Philad. 1844.)] Bleeding has been recommended by physicians of high authority ; but it is only under particular circumstances that we can expect it to be benefi- cial. In general its effects would be injurious: its use is strongly reprobated by Mr. Hunter, and it is now scarcely ever had recourse to, unless ASPHYXIA. 203 there are very unequivocal indications of great pressure on the brain. The processes above recommended should be diligently persisted in for several hours; unless evident indications of death appear, such as stiff- ness of the limbs, dimness of the eyes, &c. [When the heart has once ceased to beat, how- ever, it is extremely difficult to restore it. It is important to bear in mind the cases on record, in which resuscitation has been effected, as in as- phyxia from drowning, after an immersion of sev- eral minutes; but, at the same time, we must reject, unhesitatingly, many of the marvellous stories that have been handed down on this sub- ject. Notwithstanding these traditionary histo- ries, and the philanthropic recommendation that our attempts at resuscitation should be continued for several hours in cases of asphyxia, it is but too true, that our efforts will generally be fruitless after a perfect asphyxia of a few minutes' dura- tion. On the occasion of a melancholy catastro- phe at Albany, in the State of New York, in Au- gust, 1840, when many persons were submerged, although some of the persons were removed from the water in less than five minutes, and in two or three cases respiration was imperfectly performed, in no single instance did the medical gentlemen succeed in their well-directed efforts at entire re- suscitation. (Dunglison's Practice of Medicine, edit, cit, p. 415.)] tf The first signs of returning life are slight con- vulsive twitchings in the muscles of respiration, giving rise to gaspings and sighings. By degrees these spontaneous efforts become more regular, and natural respiration is restored; and together with this the circulation returns. Slight palpita- tion is sometimes felt at this period : on the ap- pearance of these signs our efforts must be redou- bled ; for the crisis is arrived when the life of the patient is still exposed to much hazard, and can be saved only by the utmost care and attention. Some time must yet elapse before the vivifying influence of the freshly generated arterial blood can be extended over the system generally, and especially before the functions of the brain are restored. The first return to sensation is usually attended with great suffering; and the first ex- pressions of the feelings of the patient are not those of gratitude to his benefactors, but are ra- ther those of bitter complaint and deep resent- ment. There still exists, indeed, a period of danger after the breathing has been restored and the cir- culation re-established, at which death may take place when we are least prepared to expect it. When animation returns, therefore, the patient should not be left alone, but watched lest he should require further assistance; for many have been lost from want of attention, who might otherwise have been easily saved. We may quote in illus- tration the following case mentioned by Dr. Paris, (In his Life of Sir Humphry Davy, 4to. edit, p. 69,) which happened in the neighbourhood of Windsor. A corporal of the Guards, of the name of Schofield, was seized with cramp as he was bathing in the Thames, and remained for several minutes under water. By judicious assistance, however, he was recovered, and appeared to those about him to be free from any danger, when he was attacked with convulsions, and expired. Had the respiration been artificially supported at this period, so as to have maintained the action of the heart until the black blood had returned from the brain, it is probable that the life of the soldier might have been preserved. It has sometimes happened that the return of sensation has been attended with delirium, or been followed by an attack of temporary mania. Care, indeed, is always requisite, even after the functions have been restored, to guard against the effects of morbid reaction, which gives rise to various in- flammatory and febrile states. Treatment of particular kinds of As- phyxia.—The treatment of asphyxia from the respiration of carbonic acid or any other of the irrespirable gases, is to be conducted upon the gen- eral principles above explained. The first step to be taken will naturally be to remove the body from the influence of the noxious gas, and expose it to a free and pure air. As the temperature of the body is generally raised above the natural stand- ard, the affusion of cold water on the body may be employed with great advantage ; for it acts as a powerful stimulant, in consequence of the strong impression made upon the skin, which is a very extensive sentient organ. Sprinkling cold water upon the face and breast is a milder mode of ef- fecting the same object, and is well known to have considerable effect in rousing persons in a state of syncope. The dogs which are made the subjects of experment at the Grotto del Cane, are usually plunged into a neighbouring lake after exposure to the mephitic gas, as a means of hastening their recovery. It need hardly be observed that if the temperature of the body is below the natural stand- ard, heat instead of cold should be applied. A moderate bloodletting has been strongly re- commended in this particular species of asphyxia, on the ground of its being indicated by the symp- toms of pressure on the brain. It was conceived also that the contractions of the great vessels and cavities of the heart, which are in an over-distend- ed state from accumulation of blood, would be facilitated when they were relieved by the evacua- tion of some portion of that excess. But the theory upon which this recommenda- tion rests is exceedingly doubtful. In the case recorded by Dr. Babington, bloodletting appeared to have an injurious effect, and we are, on the whole, disposed to agree in the opinion expressed by that judicious and experienced physician, namely, that the restoration of breathing is the natural and most effectual remedy to the altered balance in the circulating system. If, however, detraction of blood should be thought necessa- ry, the end will be most quickly answered by opening the jugular vein, as recommended by M. Portal. In the case above referred to, galvanic shocks were passed through the chest at intervals of half an hour, for some hours, with apparent benefit, as they seemed especially to excite to contraction of the muscles of respiration. Advantage seemed also to be derived from the forcible inhalation of oxygen gas. During the convalescence of this patient his mental power seemed to be much im- paired, and he cried bitterly when any person en- tered the room; a state of imbecility which fire- 204 ASPHYXIA. quently occurs in ordinary paralytic affections. Violent pain in the stomach is said to be occa- sionally a sequel to this species of asphyxia, for which a brisk purge is the most efficacious rem- edy. In cases of asphyxia from carburetted hydrogen gas, the treatment must be conducted upon the same general principles as in those from carbonic acid gas. Treatment of asphyxia from drowning.—On the subject of the methods to be pursued for the recovery of drowned persons, we cannot do bet- ter than transcribe the following directions given by the Humane Society in their latest Report, (The Fifty-seventh Annual Report, 1831, p. 62,) as being those sanctioned by the most extensive experience. After the body is found, particular care should be taken to employ the following means in the order described, and as quickly as possible; but in the precipitancy and confusion usual upon such occasions, cautiously to avoid every kind of vio- lence and rough usage. It is of the utmost im- portance, first, to cleanse the mouth and nostrils, strip off the wet clothes, wipe and clean the body, and wrap it in dry clothes or blankets, before it is removed, in order to obviate evaporation, and the effects of exposure to a cold medium. By either of these causes the temperature of the body would be greatly reduced, and the prospect of resuscitation diminished. The colder the wea- ther, the more desirable it will be to strip off the wet clothes, and promptly put on dry ones ; this should be done upon the spot, unless a convenient place is near at hand to carry into execution the more material preparations. An error in the first steps of the resuscitative process may be fatal. It cannot, therefore, be too strongly urged upon those who humanely assist in these early moments, and who are seldom professional men, rigidly to adhere to these few articles of instruction, that they may thus effectually prepare the way for the restoration of life. If they attempt to take more upon themselves, their intentions, though good, may be subversive of the end in view, and defeat the designs of the medical attendant More indi- viduals are lost from the irregularity and want of order in the employment of the first means, than from any other cause. The time that is spent by the humane assistant in the faithful and exact adoption of these instructions, in the first steps of the resuscitative process, is as profitably employed as the time and judgment of the medi- cal man can be ; for he cannot exert his skill till the preparations have all been made. Neither the coldness of the body, nor the length of time it may have been under water, should dishearten the assistant from a vigorous and unremitting perse- verance in his efforts. His services are, in short, incalculable. In conveying the body, it will be necessary for the assistant to forbid persons lifting the body up by the shoulders, or taking hold of the legs, with a view to carry it forward ; for in this posture it will be impossible to prevent the head from hang- ing back or bending forwards upon the breast, either of which positions of the head is injuri- ous. The best way to carry the body is to place h in a recumbent posture on the back, with the head and breast raised, on a door or board, or in a cart. When arrived in the room prepared to receive it, the body should be stripped and covered with warm blankets, and placed on a table of a con- venient height to admit of the process being em- ployed with facility ; taking care to keep the head and chest raised, and to have the nostrils and mouth thoroughly cleansed. If these are in any degree obstructed, the resuscitative process is not likely to succeed. Both the nostrils and mouth should be free and open. The inflation of the lungs is then to be performed in the man- ner we have already described, in our general ac- count of the treatment of asphyxia. While some of the assistants are engaged in performing artificial respiration, others should be employed in communicating continued heat to the body. Dry, warm blankets, bags of warm grains, or sand-bladders, or bottles of hot water, or hot bricks, or blankets wrung out of hot water, are amongst the means most readily obtained. The I body may be placed before the fire, or in the sun- [ shine, if strong at the time. Whatever may be the particular means employed, the restoration of warmth should always be assiduously pursued. Should the accident happen in the neighbourhood of a steam-engine, brewhouse, bakehouse, or any place where warm water may easily be procured, it would be of great importance to place the body in a warm bath, moderated to a degree not ex- ceeding 100°. The warmth most promising of success is that of a heated bed or blankets. Bot- tles of hot water should be laid at the bottom of the feet, to the joints of the knees, and under the arm-pits ; and a warming-pan moderately heated, or hot bricks wrapped in cloths, should be passed over the body, and particularly in the direction of the spine. A large bladder should be applied, filled with hot water, and enclosed in flannel, to the region of the stomach. The natural and kindly warmth of a healthy person, lying by the side of the body, has been found in some cases of adults, and more particularly of children, very efficacious; but the warm bath, when it can be procured, is preferable to all other means of com- municating heat. With regard to the use of friction and the ap- plication of stimulants, the observations already given in the early part of this article apply in their fullest extent. Bleeding ought never to be employed in this stage of the process; though circumstances may occur to render it necessary when the circulation has returned, and a morbid reaction has taken place. Treatment of cases of strangulation.—In the treatment of persons apparently dead from hang- ing, or any other mode of strangulation, the same means are to be enforced and persevered in as have been recommended for the recovery of those that have been drowned. The posture in which the body should be laid is the same, excepting that the head and shoulders should be raised some- what higher. The fulness of the vessels of the head may be such as to require bleeding, which, of course, will be most effectual if done in the jugular vein. The quantity of blood to be ab- stracted must be merely enough to remove the excess that exists in the vessels of the head, but ASPHYXIA. 205 . should not be so great as to weaken the powers of life. At subsequent periods of convalescence, there may, from excess of reaction, arise a neces- sity for taking away a much larger quantity. In all cases where the cause of obstruction is in the trachea, such as those arising from the introduction of an extraneous body, or the closing of the passage from disease, the operation of bronchotomy affords the only chance of saving life. P. M. Roget. [Asphyxia of the Newborn — Asphyxia neonatorum. Should any thing interfere with the due passage of the blood along the umbilical cord, asphyxia will result; not owing only to the requi- site changes of the blood in the placenta being prevented, but through the consequent interference with the circulation, which has to be effected by the cord and placenta, until the independent circu- ■* lation is established by pulmonary respiration. We can thus understand, that if the cord should come down in such a manner as to be strongly compressed for some time before delivery, asphyxia may be produced. In like manner, when the breech, feet, or knees present, there is danger to the child, unless the delivery be rapid. Occasion- ally, too, the child is stillborn in consequence of some morbid condition of the organs of innerva- tion. Thus, owing to pressure of the head in its passage through the pelvis, or to some modifica- tion in the encephalo-spinal centres, or in the nerves distributed to the respiratory organs, the function of respiration is not established, notwith- standing that the circulation appears to go on well along the cord. The child seems to be in an apoplectic condition. Asphyxia may pre-exist longer in the newborn child than in the adult, in consequence of there being less need of a highly oxygenized blood for its support. If all circulation have ceased in the cord, there can be no advantage in keeping the connection between the child and the placenta entire, espe- cially as the union cannot fail to interfere with the due application of such resuscitative means as may be deemed necessary. At times, when the child is extruded, and the placental circulation continues, the stimulus of a smart stroke on the breech arouses the dormant energies, and it imme- diately begins to cry ; but should this be insuffi- cient, the infant had better be exposed to a moderately warm temperature,— for example, to the moderate warmth of a fire, so that the air may come in contact with a large surface of the body. Generally, immersion in a warm bath is had recourse to ; but the rationale of its action is by no means unequivocal, whilst, as Dr. Kay has observed, (The Physiology, Pathology, and Treatment of Asphyxia, Lond. 1834,) it is not necessary to the application of a proper degree of warmth to the body of the child ; it prevents the beneficial effects of the atmosphere on the skin; and moreover, is found to exert a depressing influence on the nervous and muscular systems. In addition to these means, friction with the dry hand, or with stimulating liniments, espe- cially over the regions of the chest and stomach, as well as the application of spirit to the nostrils, to rouse the respiratory nerves to action, have been recommended. Should any mucus obstruct the mouth and pharynx, it ought to be removed by means of the finger enveloped in a piece of fine linen, dry, or dipped in a solution of common salt. But, after all, these means are often found unsuccessful, and it becomes necessary to have recourse to artificial respiration. This is the great reliance of the practitioner in severe cases. Whilst artificial respiration is persisted in, the cord will often be observed to pulsate, and to cease when the operation is suspended. In the still- born foetus, it is not found practicable to execute insufflation by mere pressure on the chest, in the mode advised for the adult In one case, Dr. Blundell diligently operated in that manner for fifteen or twenty minutes together, without pro- ducing resuscitation, and, on examining the child, on the following day, he found that scarcely a particle of air had entered the lungs. Nor can . insufflation be readily effected by blowing in at the mouth. The only mode of doing it effectually, is by means of a curved canula, or other analo- gous instrument. The introduction of a curved tracheal pipe into the larynx is by no means difficult. All that is necessary is to pass the fore- finger of the left hand upon the root of the tongue, as far as the opening of the larynx, and to insert the tube, held in the right hand, along the finger as a director. It will readily enter; and, by press- ing on the neck, it can be easily discovered whe- ther the instrument be in the trachea or the oeso- phagus. The lungs may then be inflated by blowing air from the lungs of the practitioner through the tube, and forcing it out again by pressing on the thorax and abdomen, and repeat- ing this five-and-twenty or thirty times in a mi- "' nute. In inflating, care must be taken that the air is not driven in too forcibly. The experiments of M. Leroy d'Etiolles, (op. cit.,) show, however, that insufflation may be performed with much less risk in the infant than in the adult, because the structure of the lungs is firmer in the former, and there is, consequently, less risk of rupture or dila- tation of the air-cells. It is no great objection that the air sent into the lungs of the foetus from those of the adult cannot be as efficacious as pure atmospheric air ; the young being, as before ob- served, not requiring such highly oxygenized air as the adult. It has been proposed that a small galvanic apparatus, like that recommended by Leroy, and before described, (p. 202,) might be used with advantage, to rouse the diaphragm to contraction. (Dunglison's Practice of Medicine, 2d edit, i, 444 : Philad. 1844.) The length of time during which the efforts of the practitioner ought to be continued, must be de- cided by his best discretion. Where, from the ap- pearance of the foetus, or other evidences, he has reason to believe that it has been for some time dead in utero, all his endeavours must necessarily fail. It is only in cases in which the child has perished in the birth, that any means can be effec- tive ; and in such case, the energetic measures already recommended, should be put in force, and not be abandoned until all hope is lost So long as there is any hesitation in the mind of the prac- titioner, as to whether the child be dead, his efforts should be perseveringly continued. 208 ASTHMA. When the attempts at resuscitation have been successful, the same attention is necessary, for a day or two afterwards, as in the varieties of as- phyxia previously mentioned ; and when there is reason to believe that the state of suspended ani- mation is dependent on, or connected with, an apoplectic condition,—as where the respiration is very slow and laborious, and there is evidence of venous engorgement of the head and neck, with pulsation in the cord, advantage is often derived from permitting a teaspoonful or two of blood to Robley Dunglison.] ASTHMA.—The term asthma, like most terms in medicine which have been transmitted to us from antiquity, in the language of the people as well as of science, has been applied to a great many different affections. Its etymology* indeed justifies its use in ail cases of difficult breathing; and it was long customary for physicians to apply it to every such case which was not produced by some known disease or other manifest cause. Very often the coexisting disease, although in fact the cause, was entirely overlooked, or, if noticed, was considered as a consequence of the disorder of the respiration. In popular language, every chronic shortness of breath, or dyspnoea, is still termed asthma, and this application of the term has certainly the sanction of many good practical and systematic writers up to a comparatively recent period. In another part of the present work, under the term dyspnoja, will be found an account of the different kinds of short-breathing, of a con- tinued form, referred, for the most part, to the organic lesions on which they depend. In the present article, it is intended to confine our views chiefly to that variety of disordered respiration which, since the time of Willis more particularly, has commonly been denominated spasmodic asth- ma, and which may be briefly defined, a difficulty of breathing recurring in paroxysms, after inter- vals of comparative good health, and usually un- accompanied by fever. History of Asthma.—Persons subject to asthma have generally more or less of warning of the approaching paroxysm. The precursory symp- toms, however, vary greatly in different cases both as to their nature and the period of their appear- ance. Some patients have indications of the coming evil even some days previously to the attack ; most have distinct notice of its approach, at least for some hours, but it occasionally attacks with scarcely any previous warning. The more common precursory symptoms are the following : a feeling of general languor and oppression, yawning, heaviness of the head or j drowsiness, distension of the stomach from flatu- lence, and a feeling of tightness across the lower part of the chest. Sometimes there is more dis- ' tinct headach, with general restlessness and fret- fulness towards evening, also dryness of the nos- trils or fauces, and other signs of slight fever.t This feverish state of the system is strikinsrly indicated by a circumstance mentioned by Floyer, namely, that in such patients as have issues the * "Aw, daw, spiro—adfa, anhelo—Utipa, spiritus—&od- lidtfii, spi ri turn difficulter traho—iodpa, anhelatio, asthma. t Vigilant, noctuqije parum et obscure incalescunt. Aretaus morb. diutur. lib. i. cap. xi. ! wounds arc apt to become sore and inflamed. Sometimes in place of dryness of the mouth or fauces, there is an increased flow of saliva, and still more frequently an increased flow of urine. In most cases, the discharge of limpid urine, which almost always is connected with the disease, does not begin until after the invasion of the paroxysm; but occasionally it comes on long before this, even a day or two previously, and is the first indication of the approaching attack.f Many other symp- toms, perhaps of a very slight kind in themselves, i but too significant to the experienced patient, j present themselves in particular cases. AH the primary disturbances most commonly become more manifest towards night, and it is often amid their increasing violence that the dispirited patient retires to bed anticipating evil. Nevertheless, sleep not unfrequently occurs, and it is only after some hours' rest, that the patient is suddenly roused by uneasy sensations, and then finds that the asthma- I tic fit is already present. In some instances the patient does not immediately awake on the inva- sion of the paroxysm, but continues in a state of half-consciousness approaching to incubus, aware of the approach of the disease, yet with scarcely the power to make even the usual instinctive efforts to resist it. On becoming thoroughly ■ awake, he finds the overwhelming symptoms to | be—a great weight, tightness and constriction of the chest, almost depriving him of the power of dilating it. He raises himself up, or gets out of bed, panting and gasping for breath, and often wheezing so loud as to be heard at a considerable distance. He calls or makes signs to have the , doors and windows opened, and frequently sits at the latter for hours together, regardless of the cold, and caring only for fresh air, " as if (in the words of Aretaeus) the house were too small and too confined for his breathing." We have known a poor patient in such circumstances, not merely remain by the open window, but lean over it rest- ing on the sill, with the arm hanging on the outside, for several nights together, and even in winter. It is a fact well worthy of notice, that in such cases the patients, although at other times very susceptible, rarely suffer, either immediately or subsequently, from the effects of the cold to which they are exposed. This circumstance is, in itself, sufficient to prove, as will be more par- ticularly noticed hereafter, how profoundly and extensively involved is the whole nervous system in the asthmatic paroxysm. But although the feelings of the patient instinctively require cool air, or, at least, unconfined air, and the trunk of the body is generally covered with perspiration, the extremities are almost always cold. The countenance is generally anxious and haggard, and the face very pale ; sometimes, however, it is flushed or even livid. There is usually a tickling dry cough; but this, as well as the other functions of the respiratory and vocal organs, is very imper- fectly performed. " The asthmatic (says Floyer) can neither cough, sneeze, spit, nor speak freely/' Almost always there is a copious flow of pale urine, as in hysterical diseases ; and at the com- mencement of the fit, the bowels are frequently relaxed, with somewhat of the impatient hurry and imperfection of spasmodic action. The pulse J Floyer on the asthma, p. 7. WhylVs works, p. 602. ASTHMA. 207 is generally very frequent, small and feeble, and occasionally irregular; and in many cases there is palpitation from the beginning of the paroxysm. Sometimes, however, the pulse does not vary greatly from the state of health, and palpitation is often absent. The great distress of the patient appears to consist in the painful constriction of the chest, and the consequent inability to inspire a sufficient quantity of air to remove the sense of suffocation. Unlike angina pectoris, which has some other points of similarity with it, the asth- matic paroxysm cannot be said to be productive of pain, in the ustial sense of that word ; nor is the mind of the patient overwhelmed with the apprehension of impending dissolution. On the contrary, the asthmatic is supported with the hope and assured conviction that his sufferings will not be of long duration. And such is generally the case. After two, three, or more hours, the seve- rity of the attack begins to decrease, the constric- tion of the chest gradually relaxes, the inspirations are easier and deeper ; the cough becomes freer, and is now attended by a loose and sometimes a copious expectoration, which is always hailed by the patient as at once the sign and means of his relief. Exhausted by his sufferings, and soothed by the contrast of ease, the patient very generally falls asleep, and the disease is for the present at an end. In many cases, with this single paroxysm the disease takes leave of the patient for the pre- sent, there being an almost perfect restoration of his health on the following day. Very frequently, however, after an incomplete resolution of the paroxysm, a second makes its appearance on the following night, and this alternation of suffering and comparative health may go on for several days before the patient is completely freed from his enemy, and a perfect intermission is established. After the paroxysms there frequently remains much soreness in the chest, arising partly from the strong but abortive efforts of the muscles to ex- pand the chest, and partly from the cough. Some- times these pains are very severe, resembling the pleuritic stitch, and might by the inexperienced be mistaken for such. However, the knowledge that any internal inflammation is a very rare con- sequence of asthma, together with the external soreness, and great increase of the pains on mo- tion, will readily point out to the experienced practitioner the exact nature of the case. On inspecting the chest'of a patient in an asth- matic paroxysm, it is found to be much less mobile than during ordinary respiration. The whole of the upper parts of the thorax seem, indeed, to be almost entirely without motion, and the inferior parts are acting within a very confined range. The abdominal muscles are, as it were, unbraced, and seem to be acting with greater freedom but much less force than usual. They appear to have lost their usual support beneath, as if the viscera were retracted from them, and they were playing backwards and forwards over a hollow space. The stethoscope conveys scarcely any respiratory sound during inspiration, except an indistinct hollow sort of murmur, altogether unlike the usual respiratory sound, and so slight as to leave it doubtful if the impression conveyed to the ear is really a sound or only a vibration. Expiration, however, is distinctly marked over the greater part of the chest, not, indeed, by the sound of healthy respiration, but by a loud sibilant or dry sonorous rhonchus, corresponding with the loud sighing wheeze audible by the naked ear. This rhonchus is often exactly like the sighing of wind through crevices ; and sometimes the tone and key of the sound approach nearer those of a moan than a sigh. The sounds are perceptible, during expira- tion, over the whole chest, even in the extreme points of the lungs; and equally so in patients whose respiration is nearly inaudible in the inter- vals of the paroxysms. In the intervals, the condition of different pa- tients varies still more than in the paroxysm. In some there remains scarcely any sign of disease either in the organ of respiration or in the general system ; but in the great majority of cases there are obvious symptoms of the suffering of both, although the patients themselves are often disposed to deny or make light of them. The contrast between their present condition and their suffer- ings in the paroxysm, is so great, that they are naturally led to underrate or disregard any slight deviations from the state of perfect health which rnay still remain ; and as they are frequently not incapacitated for the common offices and amuse- ments of society, they may seem also, to the com- mon observer, to be free from disease. But their state will rarely, if ever, stand the test of the inquiry of the physician. In almost every caso there will be found, on examination, some perma- nent local disease of the organs of respiration, or of some other organ ; or there will be found some considerable depravation of one, or of more than one important function ; or there will be a com- bination of all these, constituting a complex chro- nic disease, which may involve, in a greater or less degree, the whole system. As the asthmatic paroxysms are frequently produced, or, at least, kept up and aggravated, by the attendant morbid conditions of the system, and as the successful treatment of these, as of all diseases, will greatly depend on the precise knowledge of their nature possessed by the practitioner, it becomes a matter of the greatest importance to investigate the habi- tual state of health of asthmatic patients. When the disease has been of long standing, besides the organic or functional lesions of in- ternal organs indicated by the ordinary signs and symptoms, the asthmatic patient bears in his gait, in the form of his chest, and in his physiognomy, the indelible and unequivocal impress of his dis- ease.* The explanation of the physical alteration of the configuration of the chest, countenance, &c. is obvious, and has reference to the efforts made by the muscles of inspiration, in the parox- ysms, to dilate the chest when compressed. In a great proportion of cases there exists a marked alteration in the natural sounds of respiration, as detected by the stethoscope. The sound is either altogether absent, or very much diminished in the greater part of the chest. In some places it is more distinct, but still much feebler than in the state of health. Occasionally the feeble sounds are interrupted by a recurrent sibilous rhonchus, or click, like that of a valve. At the same time * In morbi cessationibus licet ipsi non decumbentes obamhulent, secum tamen illius signum circumferunt.— AreUeus, loc. cit. 208 ASTHMA. the chest yields over its whole extent a very clear sound on percussion. After a longer or shorter interval the paroxysm is usually renewed with all its former characters, being again succeeded by a period of ease ; and in this alternation of comparative health and suf- fering, many years, and even the greater part of a long life, are often consumed. The times of re- currence of the paroxysm vary extremely in dif- ferent cases ; and although generally more uniform in the same patients, they sometimes are very irre- gular even in them. This irregularity must, in- deed, be expected, when it is considered how very much the paroxysms are subjected to the influence of extraneous circumstances (exciting causes) which are generally altogether unfixed and uncer- tain in their recurrence. Accordingly, we find paroxysms returning after intervals of every va- riety of extent—one in a week, or in a month ; four times, or twice, or only once in a year; once in every alternate year, or only every seventh year.* The paroxysms of asthma hardly ever exhibit that exactitude of periodical recurrence which distinguishes some other diseases, and which is no less characteristic and striking than it is inexplicable, in the present state of our know- ledge. Yet some cases are recorded in which the asthmatic fits returned with singular uniformity. In one mentioned by Wainwright the paroxysms always returned at the menstrual period, during a space of seven years, (Mechanical account of the Non-naturals, p. 14 ;) and in another, by Fran- sieri, recorded in the first volume of the Memoirs of the Royal Academy of Madrid, they are stated to have recurred at every new and full moon for no less a period than one-and-twenty years. But these are most rare exceptions to a general rule, and are here noticed more for their curiosity than as deserving a place in a general delineation of asthma. The asthma affects both sexes, but is more fre- quent in the male than in the female.-}- It occurs in every stage of life, but most commonly in mid- dle life, being rare in infancy and childhood, and seldom making its first attacks in old age. It makes its appearance in individuals of every variety of constitution and temperament, a neces- sary consequence, of its frequent dependence on other diseases of accidental occurrence. It is, however, caeteris paribus, more common in per- sons of a nervous excitable temperament than in others. It is not confined to any condition of life. Some authors, particularly Ryan, (Observa- tions on Asthma,) consider it as being more com- mon among the labouring classes, taken generally, than among persons of better circumstances ; but we are very doubtful as to the correctness of this opinion, if we include in the proposition all the varieties of asthma. Our experience would rather * Memini unum regrotum, qui ex intervallis septem annorum, sexies laboraverat hoc morbo. — Heberden Comm. p. 57. f Joseph Frank (Prax. Med. Univ. vol. vii. P. II. 2, p. 383) states the proportion, as observed in his own prac- tice, to be six males to one female. Taking into account all the varieties of the disease, we consider the propor- tion of males here given as by much too great. Aretaeus (loc. cit.) gives an opposite statement:—" Huic vitio mulieres opportune sunt magis quam viri." But from the explanation given by this author of the alleged facts, it is to be apprehended thai his statement is as likely to have been the result of theory as of observation. lead us to believe, that while many other affec- tions of the lungs, particularly those of an inflam- matory kind, are more frequent among the work- ing population, this disease and some others are less so than among the middle and upper orders. In certain departments of humble life, indeed, there can be no doubt that asthma is much more prevalent than among the community generally. Under this head we may include all those persons whose occupations have an immediate influence in disturbing the respiratory functions, namely, such as are exposed to great and sudden changes of temperature, labourers whose positions mecha- nically impede the free movements of the chest, and artisans who are exposed to the inhalation of acrid fumes and substances in a state of minute mechanical division, &c, &c. Certain classes of persons in the upper order of society are likewise said to be more subject to asthma, those, namely, who have occasion to make frequent and great efforts with the lungs and vocal organs; but we suspect that this latter opinion has been founded quite as much on theoretical grounds as on actual observation. It is also stated by authors (Diemer- broek, Op. lib. p. 144; Bree, p. 175) that persons accustomed to smoke tobacco are more liable to the disease. If this is true, we ought to have a great increase of asthmatics in the present day, when the very atmosphere of England (in towns at least) is almost constantly impregnated with the fumes of this nauseous herb. Asthma seems to prevail in every climate ; but there is reason to believe that, like some other diseases of the lungs, it is more common in temperate climates than in either the very cold or the very warm regions of the earth. Joseph Frank, who resided many years in Italy, and afterwards in Poland, informs us that he found the disease more frequent in the north than in the south. (Med. Univ. Prax. torn. vii. p. 384.) Pathology of Asthma. — Systematic and theoretical writers, in attempting to explain the phenomena of asthma, seem to have been misled from the truth by partial views of the subject, and by that aim at extreme simplicity, which has so often proved a stumbling-block to medical inqui- rers. In contemplating the animal system in disease, physicians have too often been disposed to overlook the fact, so obvious in health, that it is by a variety of operations, all conspiring to the same end, that results are produced ; and, conse- quently, that if we attempt to explain the opera- tions of the living body, whether in the healthy or disordered state, on any exclusive or isolated principles, we must inevitably fail. The young practitioner cannot too much guard himself against the belief that all affections bearing the same name are of the same nature, or depend on the same causes ; as false reasoning, in cases of this kind, will inevitably lead to grievous practical errors. In examining the pathology of asthma, we have to consider not merely the phenomena of the pa- roxysm, but of the interval also ; and to investi- gate the condition not merely of the respiratory organs, but of all the other organs. In this in- quiry we shall find that, although there may exist in every case one or more conditions which more especially characterize the disease, and without AST whose presence asthma could not be said to exist, yet that there are many other conditions of the system, or of particular parts, which only occa- sionally accompany the more specific phenomena, and yet constitute, in the cases wherein they do occur, the most important features of the disease. It is upon these accidental or contingent pheno- mena that the means calculated to prevent, relieve, or cure asthma more particularly depend ; the knowledge of them, therefore, is most essential to the practitioner; and every attempt at exposing the pathology of the disease must be extremely imperfect which does not take them into account. With these reservations, which are only such as practical physicians find necessary, in almost all cases, when applying the results of theory to the actual phenomena of disease, we are disposed to coincide in the opinion of Willis, Hoffmann, Cul- len, and others, respecting the proximate cause of the asthmatic paroxysm. The theory of these great men, as is well known, was, that the asth- matic fit consists essentially in a spasm of the muscular fibres of the bronchi. In admitting the existence of this spasm, however, as essential to constitute the disease, we are very far from look- ing upon it, in a practical point of view, as in every case the most important part of the affection. On the contrary, as we have just stated, many of the other morbid conditions, general or local, which commonly precede or co-exist with this phenome- non, are of infinitely greater importance, both pathologically and in practice; but, so long as these conditions are unaccompanied by this pecu- liar affection of the muscular fibres of the bronchi, the disease is not termed asthma. Although strong doubts have been entertained by many eminent pathologists, not merely as to whether such a spasmodic affection of the bronchi actually took place in asthma, but even as to whether it was possible for it to take place in any case, we have no hesitation whatever in maintain- ing the affirmative of the proposition as true, both in the general and particular instance. Not merely the preponderance of authority, but anatomical investigation, pathological phenomena, analogy, and probability, are all in its favour. The older authors, particularly Willis and Malpighi, demonstrated to their own satisfaction the muscular fibres in the larger bronchi. But the facts mentioned by them have been not merely confirmed but greatly extended by the minuter researches of modern anatomists. In the splendid work of Reisseisen, published at Berlin in 1822, (Franz Daniel Reisseisen Uber den Bau der Lungen,) the muscular structure of the bronchi is considered as a fact readily demon- strable, and is minutely delineated from nature in the plates. " There is another apparatus," says he, « appointed for contracting the bronchi, which consists of transverse muscular fibres. As far as the cartilaginous rows extend, these fibres are in- serted into their perichondrium, on the inner edges of their extremities, diverging a little, in order to fill up the space left between the rows. They thus form a muscular tunic, extended over the fibrous or ligamentous substance which supplies the place of the cartilaginous rings behind. But when the bronchial cartilages, as they descend, cease to be disposed in regular rows, the muscu- Voi.1.— 27 »* MA. 209 lar fibres are distributed around the whole circum- ference of the canal, being attached to and extend- ing over the irregular cartilaginous plates, which here take the place of the imperfect rings. Nor do the muscular fibres disappear with these carti- laginous plates. Although become extremely fine, they can still be perceived by means of the lens, as far as it is possible to lay the tubes open with the knife, more particularly in the lungs of strong men who have died at an advanced period of life." Varnier, (Mem. de la Soc. Roy. de Med. 1779, p. 394 et seq.,) Cruveilhier, (Diet de Med. Prat torn. iii. p. 610,) Ollivier, and many other physiologists entertain similar opinions. The latter says that the bronchi contract on the injec- tion of an irritating gas. (Diet de Med. Art. Poumon, torn, xvii.) Laennec, referring to the account given by Reisseisen, considers the exist- ence of the bronchial muscles as certain, and states that he had himself verified their presence in the tubes of less than a line in diameter. He adds, " that, although it appears difficult to follow the muscular fibres further, analogy leads us to admit their existence in the smaller branches, and perhaps even in the air-cells." (De I'Auscult Med.) A strong analogical proof of the mus- cularity of the smaller bronchi, is afforded by the muscularity of the trachea, a circumstance ad- mitted by all physiologists. It would certainly appear, a priori, that this part of the canal had as little need of muscular fibres as the bronchi. In- deed, it seems not merely certain that the bronchi possesses a power of muscular contraction, and, consequently, of lessening their caliber, but that the smaller ramifications, at least, in other words, the whole lungs are endowed with an active power of dilatation, altogether independent of the movements of the chest This power seems demonstrated by numerous experiments on living animals, by the phenomena which have occasion- ally been observed in the case of wounds of the chest, and by various circumstances, both of a pathological and physiological nature, which have been ascertained in the practice of auscultation.* The main phenomena of the asthmatic parox- ysm are precisely such as would result from a morbid contraction of the bronchial muscles; and several of them seem quite inexplicable on any other principle. The extreme suddenness of the attack in many cases ; its equally speedy removal in others, some- times naturally, sometimes through the effect of remedies; the character of the dyspnoea and of many of the general symptoms ; the state of the pulse, the urine, the countenance, the skin, the intellec- tual functions, &c. &c. all clearly demonstrate it to be of the kind usually termed nervous or spas- modic. The only questions that can be mooted relate to the exact, part or parts of these organs, in which the spasm is fixed. Is it in the muscles of the larynx and glottis ? Is it in the smaller bron- chial ramifications ? Is it in the external muscles * See, on this subject, the following authorities; Diet. des Pr. Med. art. Poumon ; Rout, Journ. de la Soc. de Med. torn, xxxiv.; also, his Melanges de Chirurgie, p. B7; Ctoquet, de rinfluence des Efforts sur les Organes Thoraciques, Paris, 1P20; Chaussier,TablesSyncptiques; Laennec, De I'Auscultation Mediate; Michaelis, 'n Rich- ter's Chir. Bibl. vol. vi. Also cases of Boerhaave, StoU, Bruns, Voigtel, Larrey, &c. 210 ASTHMA. of respiration ? Or is it in more or fewer of these parts at the same time ? These questions demand a moment's conside- ration. There are several forms of spasmodic stricture of the upper portion of the air-tube, more particu- larly of the glottis, well known to practical phy- sicians. The more common of these occur in infants and young children ;' but they are con- fined to no particular period of life. An old lady, a friend of the writer of this article, has all her life been liable to attacks of this kind, which seize her instantaneously, after long intervals, and, during their continuance, entirely prevent inspira- tion, and thus threaten immediate death. After a few seconds the paroxysm subsides, without leav- ing a trace behind it The disease described by Dr. John Clarke as a " peculiar species of convul- sion in infant children," and of which a more complete account has recently been published by Dr. Marsh, (Dublin Hosp. Reports, vol. v. p. 600,) is evidently a spasmodic affection of the same kind, but less strictly confined to the glottis than in the case just mentioned. In the infantile dis- order, the spasmodic disposition frequently extends over the whole muscular system, inducing general convulsions. The disease frequently termed spas- modic croup, and which occurs also most com- monly in children, but at a somewhat later period, consists, in like manner, in numerous instances, in a spasmodic affection of the glottis ; but, in this case likewise, the spasms frequently extend further, in many instances affecting the greater part of the air-tubes. When this is the case, the disease is, in truth, a form of asthma, and ought rather to be named infantile asthma than spasmodic croup. A few practical writers represent the common form of asthma, in adults, as consisting almost exclu- sively of spasm of the same parts; and, among others, Dr. Wilson Philip. " The spasmodic asth- ma (says this author, in his recent work,) appears, properly speaking, not to be a disease of the lungs themselves, but of the parts of the upper extremity of the wind-pipe, in which the contraction of the passage of the air, by spasm of its muscles, pro- duces the violent struggling for breath which attends its paroxysms." We shall examine the validity of this opinion after having noticed the other theories. The chief of these is that which represents the asthmatic paroxysm as consisting in a spasm of the external muscles of respiration. One would imagine that it could be no very difficult matter to determine, after an inspection of the naked chest of a patient in a fit of asthma, whether the external respiratory muscles were in a state of spasm or not: and we cannot help sus- pecting that some of those who have been the strongest advocates for the affirmative of this pro- position, have taken but little trouble to ascertain its truth in the most natural and simple,way. Our own observations have invariably led to the con- clusion that all the muscles of which the action is perceptible, are, during the paroxysm, exerting themselves strongly to dilate the chest; and there are the strongest reasons for believing that the muscles, the action of which is concealed, are in the same condition. It is universally admitted that expiration is, in ordinary cases, effected, in a great measure, by the mere mechanical sinking of ! the walls of the chest, upon the cessation of the active muscular efforts of inspiration. The rih» descend and the diaphragm ascends, and necessa- I rily, upon the relaxation of the muscular fibres, I the contraction of which had enlarged the cavity ! of the chest. And if we take into consideration the immense superiority of power of the muscles of inspiration, and remember that these are all, during the paroxysms, exerting themselves to the utmost to dilate the chest, it seems extremely improbable that the power of their feeble antago- nists, however exerted, could resist them. But independently of these negative proofs, we have many direct ones that the principal site of the spasm is in the air-passages, and that the instinctive and voluntary efforts of the muscles of inspiration are almost exclusively directed to over- come this. Some of these direct proofs are the following. Asthma, as we shall soon see more particularly, is very commonly dependent on a diseased state of the bronchial membrane, and the attacks are frequently induced by an increase of this state. The resolution of a paroxysm is almost invariably accompanied by a great increase of secretion from the bronchi, which could hardly be expected to be the case if the affection were seated either in the muscles of the glottis or in the exter- nal muscles of respiration. Diseases of the bron- chi, which produce a similar contraction of the air-passages by mere swelling of the membrane, namely bronchitis, and an affection producing nearly the same physical condition of the parts from a sudden congestion of the blood-vessels, give rise to a state of respiration very like that which obtains in the asthmatic paroxysm. Aus- cultation of the respiration, during the paroxysm, discovers particular sounds over the whole extent of the chest, which sounds can only have their site in the bronchial tubes; and as these sounds come on and go off with the paroxysm, it seems a necessary conclusion that they depend on the physical changes produced by this, and that those changes take place in the bronchi. Common wheezing, as heard by the unassisted ear in asthma and in most cases of dyspnoea, may exist in a very marked degree without the auscultatory rhonchus, which may be considered the pathognomonic sign of bronchial infarction from whatever cause de- rived. But while, for these reasons, we think it must be allowed that the main site of the spasms which constitute the asthmatic paroxysm is the bronchi, we are by no means of opinion that they are exclusively confined to these. On the contrary, we think it very certain that not only all the parts already mentioned, but others still more remote, are frequently involved in the same disordered action. This is what must have been anticipated from a consideration of the very nature of the affection. In all spasmodic diseases there is a disposition towards extension of the spasm from the original or principal site, and, indeed, this fact is perhaps more easily explained on physiological principles than the restriction of the spasm to one part or one set of muscles could be. In all these cases, if the nervous centres are not primarily affected, they invariably become so subsequently j and the circumscription of the local manifestation of the spasm to the muscles first disordered thence ASTHMA. 211 becomes very improbable. Besides, we know that muscles whose actions are at all associated, are very liable to suffer generally when one or more of the class are morbidly affected. And, in the present case, we admit that the muscles both of the larynx and the chest are frequently involved in the progress of the paroxysm. They are, how- ever, we believe, in almost every case, affected secondarily, and it is therefore impossible to sub- scribe to the opinions of those who wish to make them the chief site of the asthmatic spasm. Other muscular affections, of a spasmodic kind, are not uncommon in the paroxysm of asthma. The sudden calls to empty the bowels are no doubt partly owing to a morbid action of the muscles concerned in this process ; although chiefly, per- haps, the consequence of the same general disor- der of the nervous and vascular systems, which gives rise to the pallid and shrunk state of the surface, the flow of limpid urine, &c. In a young man, now under our care, subject for some years to periodic asthma, which generally attacks him during sleep, the first indication he has of the invasion of the paroxysm is an involuntary spas- modic twitching of the right foot or leg, of which he is conscious for some time before he is fully awake, and of which the increasing violence awakens him. The twitching always leaves him on his becoming fully awake, but he then finds himself under the full dominion of his asthma. It must not be imagined from any thing that has been stated, that we consider the asthmatic paroxysm as consisting exclusively of a muscular spasm of parts otherwise healthy. This, indeed, may be the case in a few instances; but it is not to be doubted that, in the great majority of cases, the spasm not merely affects parts previously dis- eased, but that the phenomena of the paroxysm are partly dependent on, and greatly modified by, these very lesions co-existing with the spasm, aggravating it, and, in turn, being aggravated by it. Varieties of Asthma. — Several methods present themselves for classifying the different forms of asthma met with in practice. Our limits do not permit us to enter into any discussion as to their respective merits, nor to give our reasons for preferring that which is here adopted, further than to state that we think all classifications of diseases ought to be founded, when practicable, on the pathological condition of the affected parts. On this principle we shall divide cases of asth- ma into two classes or groups, according as there exists a sound or a diseased state of the bronchial membrane in the intervals of the paroxysms; terming those of the first class nervous asthma, and those of the second catarrhal asthma. We shall now notice these in order. I. Nervous asthma.—The characteristic quality, or, at least, the most manifest physiological pecu- liarity of the individuals subject to nervous asthma, is the extreme susceptibility of their nervous sys- tem. They are said, in common language, to be nervous, or to possess the nervous temperament. This is the asthma of hysterical females, and is indeed, in many cases, only one of the multiform aspects of hysteria. It, however, occurs equally in males, and in females who have no other symp- tom of hysteria. Every one must admit that in persons subject to asthma mere moral causes fre- quently suffice to induce a paroxysm; and it seems, at least, extremely probable that similar causes, when more intense, or when the individual susceptibility is greater, may give rise to the dis- ease in persons not previously subject to it. The records of practical medicine contain innume- rable examples of the influence of the nervous system over the asthmatic paroxysm. In Dr. Parry's posthumous works some curious cases of this kind are given. In one, severe dyspnoea with irregular action of the heart was instantaneously produced, in the presence of Dr. Parry, by mental agitation. The paroxysm lasted eight or nine days, and terminated with considerable mucous expectoration, showing, by the way, the power of a mere nervous affection to produce, by its con- tinuance, local disease. In another case of old and well-marked asthma, the same physician wit- nessed the instantaneous removal of the paroxysm by fright Many cases of an analogous character might be quoted from authors, and most of our readers of long experience in practice must have met with similar instances. The following case, extracted from Dr. Whytt's work on the nervous system, is a striking example of the disease now under consideration. " A girl, healthful, well- made, and of a seemingly good constitution, began, at the age of seven years, to complain of a pain at the lower part of the sternum ; this pain, which returned after no certain intervals, became gradu- ally more severe during the space of nearly two years, after which, in place of it, the patient began to'be affected, at times, with a difficulty of breath- ing, which returned frequently, without observing any certain periods ; as a week, a fortnight, or a month would sometimes intervene between the fits. She was generally seized with the fits all at once ; and after breathing with the utmost diffi- culty for half an hour, sometimes more than an hour, she would, of a sudden, become perfectly well, and fall a-dancing immediately after with her companions. It was observable that this girl had no complaint of her stomach, no cough, nor other apparent fault in her lungs ; nor did she usually expectorate phlegm when the fit went off; and, except in time of the asthmatic paroxysm, breathed with the same ease as any person in perfect health." ( Whytt's Works, p. 603.) Some curious examples of nervous asthma are given by Laennec in his Treatise on Diseases of the Chest One patient was instantly seized with great difficulty of breathing on attempting to travel in one par- ticular direction, and was instantly relieved on turning back. This happened repeatedly. Another, an old asthmatic, subject to slight catarrh, was invariably seized with a paroxysm if his lamp hap- pened to go out during the night, although he was asleep at the time. (De I'Auscultation Med.) A singular instance of the influence of the nerves in producing asthma, without any local disease of the lungs themselves, is furnished by a curious affec- tion prevalent in the east among persons addicted to the abuse of opium. It is a kind of spurious or factitious asthma, which attacks opium-eaters on being suddenly deprived of their habitual dose; in the same manner, and, no doubt, for the same reason, that delirium tremens attacks the spirit- drinkers of colder climates. The patient is seized 212 ASTHMA. with extreme breathlessness, exactly resembling that of asthma; the countenance being haggard, the pulse rapid, and the eye such as we should expect to find in a patient affected with phrenitis. If the disease is not relieved, it proves fatal in the course of a few hours. Some opium given in time will immediately relieve all the symptoms. (Hen- derson in Edin. Journ. vol. xxiv. p. 51.) For the sake of those who are curious in noso- logical arrangements, rather than as being of any practical value, the following classification of the various cases which come under the head of nerv- ous asthma is submitted to the reader. 1. In a very small proportion of these cases we cannot detect any disorder of the system, general or local, which can be considered as at all in- fluencing the occurrence of the paroxysms. These may be termed cases of pure nervous asthma. 2. In an infinitely larger proportion of cases we find more or less of disease in the system generally, or in some of the principal organs; and which disease appears to be the remote cause of the paroxysms, influencing the bronohial muscles indirectly through the intermedium of the brain. Such cases may be termed sympathetic nervous asthma. This order may be subdivided into species, according to the nature or site of the af- fection which constitutes the remote cause of the paroxysm. For an account of these we refer to a subsequent part of this paper, where they will be noticed under the head of predisposing causes. It could lead to no useful end to notice them here in detail. 3. In a third group may be included, under the name of symptomatic nervous asthma, (1) those cases which depend on diseases immediately af- fecting the pulmonary nerves themselves, and (2) those in which the paroxysms are directly induced by organic disease of the lungs, head, pleura, &c. Of the former kind there are various examples to be met with in authors. In a case of asthma related by Ferrus, a large ossification was found in the centre of the pulmonic plexus, and which compressed some of the nerves. (Diet, de Med. torn. iii. p. 109..) In a case of fatal dyspnoea, Beclard could discover no cause of the disease but a tumour on one of the diaphragmatic nerves. A nearly similar case is recorded by Andral (Diet. de Med. Prat. torn. iii. p. 109.) ; and Parry men- tions a case of "dyspnoea occurring by fits of ag- gravation, and at last proving fatal, without any symptoms of local pneumonic disease," in a per- son who had " thickening about the upper part of the vertebrae of the neck, with some degree of distortion, from venereal affection." (Posthumous Works, vol. ii. p. 16.) The influence of spinal irritation in producing palpitation and other irre- gular action of the heart, is well known ; and we apprehend that many of the chronic dyspnoeas and irregular asthmatic affections which we meet with in persons who are deformed, arise as frequently from disturbance of the spinal marrow produced by the distortion, as from disease of the lungs themselves. The second subdivision of this group of cases includes those fits of spasmodic dyspnoea which so frequently accompany diseases of the heart, hy- drothorax, &c. Although such affections may ojme within the logical definition of asthma in as far as the spasmodic condition of the bronchi is concerned, (and they are, therefore, alluded to in this place,) it would be to confound all rational principles of pathology to consider them as such in practice. They may very properly be named spurious asthma,- but the consideration of their nature and treatment belongs to another place. (See Dtspnoja, and the articles which treat of the diseases of which they are incidentally symp- toms.) II. Catarrhal Asthma.—In studying the vari- ous cases of asthma met with in practice, while we find, in the vast majority of instances, some fixed affection of the bronchial membrane, we find great variety in the nature, and still more in the degree of this affection. In one class of cases there seems to be merely some peculiar modifica- tion of the sensibility of the bronchial membrane, which renders it susceptible of being excited to morbid action by various external influences. In others, however, and in an infinitely larger num- ber, there exists either an habitual catarrh of a formal character, or such a predisposition to be affected by catarrh, as practically to amount to a like condition of the parts. In many persons thus circumstanced, there is such a susceptibility to be affected by cold, and to catch cold, that they can scarcely ever be said to be free from it. The least change of dress, the slightest draught of air, the most trifling dampness of shoes and stockings, or even standing for a minute on a stone floor, will give an instantaneous chill, and produce an im- mediate and sensible change in the condition of the bronchial membrane. In many persons this morbid susceptibility to cold, fostered and perpe- tuated as it is by improper management, arises to so great a height as to be extremely inconvenient In the case of persons in easy circumstances, we sometimes see the susceptibility to cold so great, or so exaggerated by the hypochondriacal appre- hensions of the patient, that life is almost devoted to the one object of escaping cold; and it must be owned, with very indifferent success. Although very great susceptibility to cold, and to be affected by catarrhal affections, may un- doubtedly exist without any discernible fixed affec- tion of the bronchial membrane, yet this is only in the earlier stages of such states. Sooner or later, and generally very soon, the mucous mem- brane becomes disordered permanently ; and it is this local disease of the lining membrane of the air-passages, together with the general liability to be affected by slight degrees of cold, which con- stitutes the most common state of persons subject to asthma. Between the extreme limits of this bronchial affection, from mere increase of sensi- bility up to the most acute inflammation, the degrees of shades are infinite. We can only in this place allude, and briefly, to the most marked of these. For fuller histories of these affections, we must refer to other articles in this work, par- ticularly to Bhovchitis,Catarrh, [Pclmonari] Emphxsema, &c. The catarrhal affections with which the asth- matic spasm may be combined may be either acute or chronic. As being by far the most com- mon, we shall notice the chronic varieties first. Indeed, we shall only notice the acute forms in compliance with general custom, as we wish our ASTHMA. 213 observations in the present article to be considered as applying almost exclusively to a disease of a chronic nature. 1. The first variety of the chronic catarrhal asthma which we shall notice is ranged under the present head more from analogy than from any certain proof of its being essentially of a catarrhal nature. Its essential characteristic seems to be a peculiar morbid sensibility, or irritability of the membrane lining the bronchi, rather than any sensible physical alteration of it. If a name is desired for it, it might, in the language of Laen- nec, be termed latent catarrhal asthma. No doubt, if our means of investigation were suffi- ciently minute, we should find a physical cause in the membrane itself for the morbid irritability ex- hibited by it on the application of certain stimuli; but as our senses do not enable us to detect any such cause, we must content ourselves, for the present, with noticing the resulting phenomena. We are disposed to infer that the affection of the membrane is of the catarrhal kind ; — firstly, be- cause, in incipient catarrhs, we have often the same susceptibility of the membrane, without any other symptom of catarrh ; secondly, because the asthmatic or dyspnoeal paroxysm, in the cases now under consideration, frequently terminates in acute catarrh; and thirdly, because this state of morbid sensitiveness almost always degenerates, eventu- ally, into some of the forms of chronic catarrh. In its progress, the first stage is the dry catarrh, and this soon passes into emphysema. This peculiar irritability of membrane in many cases continues perfectly latent until rendered manifest by the application of certain stimulants. Some individuals are affected by only one kind of substance, others by two or more. Ipecacuanha seems the substance which, of all others, exerts the greatest influence in cases of this kind. Every practitioner of experience must have met with individuals in whom this idiosyncrasy was so strong that they could not remain in the same room in which a vessel containing powdered ipe- cacuan was opened, even at a distance from them, without becoming immediately affected with a paroxysm of dyspnoea more or less resembling asthma. We have ourselves known some cases of the kind, and have had several others pointed out to us by medical friends, in our own neigh- bourhood. Other persons, not affected by ipeca- cuan, suffer similar inconvenience from other substances in a state of minute diffusion in the atmosphere; such as the smoke of sealing-wax, the effluvia from hay, the fumes of chlorine, car- bonic acid gas, &c. &c. In some of these cases, the dyspnoea passes off speedily ; in others it lasts a considerable time; and in some it terminates in formal catarrh.* * See a case of this kind in Parry's Posthumous Works, vol. ii. One of the most interesting examples of this peculiar effect of ipecacuan is the case recorded by Dr. Scott in the Philosophical Transactions for 1776. The patient was the wife of an apothecary, and became sub- ject to regular attacks of asthma after her marriage. For some years no particular cause was suspected; but it was at length discovered that the paroxysm invariably came on when ipecacuan was powdered in the shop. This practice was accordingly discontinued, and she con- tinued well eight or ten years; until one day, when her husband again brought home some powdered ipecacuan, and opened the packet in order to put the drug into a bottle -his wife not being far off at the time, and in 2. The next variety of catarrhal asthma is that which is complicated by the disease termed dry catarrh by Laennec. It may, therefore be deno- minated dry catarrhal asthma. It is, perhaps, the most common form of asthma. For an account of the pathology of the catarrhal affection, we must refer the reader to the article which is spe- cially devoted to it. It will be there seen that the progress of this affection inevitably leads to the morbid dilatation of the terminal bronchi or air- cells ; a pathological state denominated pulmonary emphysema by Laennec. As the asthmatic pa- roxysms seldom occur in an early stage of the dry catarrh, it very generally happens that the emphy- sematous condition of the lung coincides with this variety of asthma, a combination which explains the results of the exploration of the respiration in this disease, noticed in the beginning of the present article. The co-existence of emphysema with asthma must be looked upon as of most unfavour- ble augury in relation to the cure, as the former disease, when once fully formed, is hardly suscep- tible of cure.. In the variety of asthma dependent either on the dry catarrh simply, or on this com- bined with emphysema, the precursor and imme- diately exciting cause of the paroxysm, is almost invariably a fresh attack of cold, or, at least, some aggravation of the habitual catarrhal state. 3. The next variety of catarrhal asthma is that which is combined with the common chronic mu- cous catarrh. It is the humoral asthma of the old authors. In conformity with the names given to the preceding varieties, it may be denominated the mucous catarrhal asthma. This form of catarrh is occasionally the consequence of those last de- scribed ; but it is still more frequently produced by repeated attacks of the acute catarrh. It is the common chronic catarrh, frequent in old age, and by no means uncommon in youth. It is often the sequel of acute bronchitis, and is, indeed, itself only a form of the same disease in a chronic state. Although the asthmatic paroxysm frequently su- pervenes to this state, our own experience inclines us to believe that it complicates still more fre- quently the latent and dry forms of catarrh. Indi- viduals subject to the chronic mucous catarrh are frequently said to have fits of asthma when their habitual dyspnoea is merely increased by the super- vention of a fresh cold, or by the aggravation of the habitual chronic inflammation from any other cause. No doubt such attacks are often accom- panied with a slight spasmodic constriction of the bronchi; and therefore they are, strictly speaking, entitled to the name of asthma : but paroxysms of sudden dyspnoea, in which the spasmodic affec- tion is the most conspicuous phenomenon, are certainly not very common ; indeed, they must be considered as very uncommon, when viewed rela- tively to the extreme frequency of chronic mucous catarrh. The preceding are the chief affections of the perfect health." This occasioned a most violent fit of asthma, which lasted eight days, becoming better during the day, and much worse at night. This patient's fits from ipecacuan usually lasted a few days, and went off commonly by an expectoration of viscid mucus. Quere, As most of the cases of asthma from ipecacuan have oc- curred in people connected with drugs, are we to con- clude that the peculiar idiosyncrasy is much more general than is supposed, and is not evinced only because other persons do not come in contact with this drug? 214 ASTHMA. bronchial membrane, of a chronic kind, with which the asthmatic paroxysm is complicated. There are some others of an acute character yet to be noticed, and which, when co-existing with the paroxysms of asthma, entitle this to the name of the dcute asthma. Two forms of this species are met with in practice, sometimes sufficiently well marked to be readily distinguished; but fre- quently, like the other species of asthma, so inter- mingled as to render the discrimination impracti- cable. 1. The first of these two varieties may be termed the acute congestive asthma. Were it not that we frequently see the most extensive inflam- mation and consequent tumefaction of the bron- chial membrane, without very great difficulty of breathing, certainly without any of that extreme and peculiar dyspnoea which characterizes the asthmatic paroxysm, we might agree with Parry in opinion that mere vascular congestion, from sudden determination of blood to this membrane, might account for all the phenomena of asthma. And there can be no doubt that, in a certain class of cases, this determination of blood is not merely the precursor of the spasm, but that it constitutes the greater part of the pathological condition of the affected parts. Of course, there is some modi- fication of the nervous condition of the membrane previously to the afflux of blood to it; but it is extremely improbable that this modification is of a spasmodic nature : on the contrary, it can hardly be doubted that it is the morbid congestion of the blood-vessels which irritates the muscular fibres into spasmodic stricture. In this mode of viewing the case, (and the same observation is applicable to all the forms of asthma dependent on disease of the bronchial membrane,) we must regard the asthmatic paroxysm rather in the light of a con- tingency than as constituting an essential and necessary part of the pathological state. The nervous modification, the determination of blood, the vascular congestion, or catarrhal turgescence may exist without any spasm ; and this may or may not supervene according as it is promoted or opposed by individual peculiarities of a general or local kind, the nature of which it is impossible for us to ascertain. The external phenomena will necessarily vary with the pathological condition of the parts ; but it is probable that phenomena which appear to us similar may be the effect of different conditions. Thus it is probable that a paroxysm of like violence may equally follow an extensive congestion with a slight spasm, or a slight congestion with a great spasm ; and all the various and relative modifications of which these states are susceptible will produce a great variety in the phenomena of the disease. A strongly marked case of congestive asthma is recorded by Dr. Parry, in a person " who, without any previous disorder of the chest, died in fifteen or twenty minutes, with every symptom of spas- modic asthma ;" and in whom, on dissection, the only morbid appearance observed was " a complete suffusion, of a damask-rose colour, amounting in some places, almost to blackness, of the entire mucous membrane of the trachea, and of all the ramifications of the bronchia." (Parry's Elements of Pathology, § 474.) Cases so strongly marked as this are extremely rare. We are disposed to look upon them as analogous to that disease of the lungs termed, by Laennec, pulmonary apo- plexy. There is another form of congestion of the bronchial membrane, immediately dependent on disease of the heart, which is a common cause of dyspnoea in such cases, and is also sometimes the source of the asthmatical paroxysm. The state to which we allude is almost of a mechanical nature, being the direct result of impeded circula- tion. In certain habits the congested state of the bronchial membrane may produce simple dyspnoea, in others asthma; and in many it is at once indi- cated and cured by haemoptysis. In most cases of this kind, the other mucous membranes, as well as the venous system generally, are overloaded with blood. 2. The last variety of catarrhal asthma which we shall notice may be termed acute catarrhal asthma. It only differs from the last in coming on more slowly, and in being complicated with a common catarrhal affection of the bronchial mem- brane, instead of a rapid congestion of the same. Reasoning it priori, one might expect cases of this kind to be very common. Such, however, is not the fact. The disease which has been termed the • hay asthma, when amounting to that degree of paroxysmal violence deserving the name of asthma, belongs to the form now under consideration; although this affection is much more properly designated by the name of summer catarrh. In some cases of this kind, the dyspnoea is certainly considerable ; in a small proportion of cases it is, according to Dr. Bostock, the only symptom : but we have not met with a single well recorded case in which the dyspnoea assumed the true asthmatic character.* In that class of persons, formerly noticed, in whom ipecacuan and certain other exhalations have the effect of producing great bronchial irritation, the difficulty of breathing is sometimes preceded by an acute catarrhal state of the membrane. The two species of asthma last described com- prehend those cases, of not very unfrequent oc- currence, which were first particularly noticed by Millar under the name of the acute asthma, and which, on the continent more particularly, have very generally been since termed Millar's asthma, from this author. They also include many of the cases which have been described by authors under the name of suffocative catarrh, false croup, spas- modic croup, suffocative asthma, &c; although many cases so denominated have been cases of pure bronchitis. It is hardly necessary to repeat what was formerly stated, that both these forms of acute asthma, more particularly the acute catarrhal asthma, are merely different shades of that exten- sive pathological state which comprehends all the forms of acute irritation of the mucous membrane of the lungs, from the slightest febrile turgescence up to the most violent inflammation. It is only the accidental complication of spasm that lends to it its peculiar features ; and in our treatment we must never forget, that however prominent, or however (for the time) important this complication may be, it is only a consequence of a state yet more important. When the spasm is removed, •See Dr. Bostock's Papers, Med. Chir. Trans, vols. I. and xiv.: also Dr. Parry's Posthumous Works, vol. ii. ASTHMA. 215 we may have still a formidable disease to treat It is truly remarked by Millar, that the acute asthma frequently lays the foundation for the chronic asthma. In the present paper we wish principally to confine our views to the chronic disease, which alone is properly termed asthma. The acute asth- ma more properly belongs to the articles which treat of the diseases of which it is merely a symp- tom. It is hardly necessary to observe that two or more of the above forms of asthma, or rather of the above pathological states, may co-exist in the same individual. We may have the spasmodic paroxysm immediately excited by purely nervous causes, induced in persons already affected with disease of the bronchial membrane, while all the varieties of the symptomatic asthma may equally affect individuals who have or who have not such an affection of the membrane. We may even have organic disease of the heart, lungs, or pleura, together with disease of the bronchial membrane, and yet the immediate exciting cause of the asth- matic fit may be some irritation situated in a remote organ. In like manner, the acute forms of the disease may supervene to the chronic. All this complexity forms no substantial objection to the classification we have just given of the varie- ties of asthma. Our object is not to exhibit a specimen of logical nosology, according to the ancient approved method, but merely to lay before the reader such a catalogue of the varieties as he is likely to meet with in practice, founded upon differences in their pathology. If the student has once accurate views of the true nature of diseases, he will have little difficulty in discriminating all the varieties of them which it is of importance to know. In referring to the preceding investigation, it may be useful to give a brief recapitulation of some of the principal points which seem estab- lished. 1. In the disease properly termed asthma, there is always present a spasmodic contraction of the muscles of the bronchi, and sometimes a similar state of the muscles of the trachea, larynx, and external muscles of respiration. 2. In a small proportion of cases, the spasmodic stricture may take place (idiopathically or sympto- matically) without any previous disease of the af- fected parts. 3. In the great majority of cases, the spasmo- dic constriction is dependent on a pre-existing irritation of the mucous membrane of the air-pas- sages. 4. Phenomena of a very similar character are sometimes the consequence of a congested state of the mucous membrane of the air-passages, with- out any attendant spasm. 5. The congested or tumefied state of the mu- cous membrane almost invariably accompanies the paroxysms, whether this state be a cause or a con- sequence of the spasm. 6. The violence of the paroxysms is modified no less by the degree of the congestion than by the degree of the spasm ; a great congestion with slight spasm producing, probably, the same re- sult as a slight congestion with a great degree of spasm. 7. In some cases, the tumefied or congested | state of the bronchial membrane passes off en- tirely with the spasm, without any exhalation from the vessels or augmented secretion from the mucous follicles. More commonly there is a si- multaneous relaxation of the spasm of the mus- cular fibres, and an exhalation from the mucous coat This exhalatior, most commonly puts an end to the dise . time ; not unfrequently, however, the unig «=*: ,e passes to a more perma- nent state oi~ - .airimatory irritation, under the form of pulrrK'»a-i- ^;t;s, MorM* l> • j(. * a com- plete history doubt, that, in the great majority of cases, a mild and equable climate is much more favourable to the asthmatic than one that is cold and variable. Such a cli- mate proves beneficial in various ways, more espe- cially in the cases dependent on any form of chro- nic catarrh. It tends directly to remove the very basis of the disease—1st. by the direct application to the part of air of a milder and more agreeable temperature ; 2d. by rendering the attacks of acute catarrh less frequent, and thereby affording longer intervals for the restoration of the irritated membrane; 3d. by promoting the cure of the accompanying disorders, which frequently exert a most unfavourable influence, both on the struc- tural alteration of the membrane, and on the spasmodic affection of the bronchial muscles; and more particularly the disorders of the diges- tive organs and the skin; 4th. by enabling the patient to improve the general health and strength, and to fortify the system against the impression of cold by constant exercise in the open air, and by the uninterrupted use of the cold bath through- out the year. For more particular information on this part of our subject, we must refer to the arti- cles Change or Air and Climate in the pre- sent work, and to the very valuable work of Dr. [Sir James] Clark on the general influence of climate on chronic diseases.* Mineral waters.—These remedies have been much employed in asthma, particularly on the continent We shall borrow from the author just quoted the few remarks which we intend to offer on this part of our subject. " When asthma is complicated with chronic irritation of the bronchial membrane, or of the digestive organs, or with a congested state of the hepatic system, or an unhealthy skin, a course of warm mineral water will prove of much benefit, by relieving those morbid affections which often induce and always aggravate asthma. There are several mineral waters on the continent which have a high reputation, and we believe deservedly, in this class of diseases. Of this kind the springs of Ems on the Rhine, of Bonnes and Cauterets among the Pyrenees, and of Mont D'or in Auvergne, are held in the greatest estimation. But there is more difficulty in selecting a mineral water for the asthmatic patient than for any other; r^t .T,ne Influence of Climate. Second Edit. Lond. 1830. H;J.r.. J' ui"'.eor thf ti,le of the Sanative Influence of Climate, Lond. 1841 | ASTHMA —ASTRINGENTS. 229 as the source, most suitable to the diseases which I complicate it, may be in a situation which decid- ■ edly disagrees with the asthma. However well suited the waters of the Pyrenees or of Mont D'or might be to the bronchial disease, it would be useless to propose a residence at either of those places to an asthmatic person who could not breathe at a great elevation ; or to send him to Ems or Carlsbad who could not live in a valley ; although the waters of these places might be ad- mirably adapted to the bronchial or abdominal! diseases with which the asthma is complicated." The mineral waters of England, of an analogous character, may he used in the same cases ; and where abdominal plethora exists, the aperient waters of Cheltenham or Leamington will be be- neficial in relieving this. The waters of Bath have also been found beneficial in some cases ; but in general they are not well suited to the pul- monary affection, however they may be so to some of the complicating diseases. Diet. — The diet in all chronic diseases is a matter of great practical importance. It is of more especial importance in asthma, because dis- order of the stomach is so frequent a concomitant and even a cause of the disease. All the good writers on asthma are strong advocates for mo- deration in diet; and there is no disease in which patients are more unanimous on the same point Floyer is particularly zealous against excess both in eating and drinking. " Hunger and thirst (he says) are the best cure for the asthma, especially little and very small drink." " The less the asth- matics are nourished, (he says, in another place,) the longer are the intervals of the fits, and the clearer is their breath." The principles which ought to regulate the diet are few and simple ; but the practice must be modified by the circum- stances of individual cases. Temperance and moderation are universally applicable and neces- sary, as is also habitual vigilance against being seduced from the regularity of invalid habits. The particular system of diet is indicated much more by the concomitant affections than by the asthma itself. If the disease is unattended by any very decided disorder of structure in the bronchi, or elsewhere, the diet may be more generous and less strict than under a different state of things. If there is marked affection of the bronchi, with little disorder of other parts, the only circumstance of much importance to be attended to respecting diet, is that it does not tend, by being overfull, directly to increase this bronchial affection, and to induce other disorders which might aggravate the primary disease. But in almost all cases of asthma, we have already other disorders which tend powerfully to aggravate and keep up the bronchial affection, and in the alleviation or cure of which diet is of paramount importance. In this list we may include dyspepsia with its numerous progeny of general and local diseases, plethora, gout, gravel, diseases of the mucous membranes generally, of the liver, brain, uterus, skin, h, nu- tritio, is a term used in medical language to sig- nify a deficiency in the nutritive powers of a part, in consequence of which its natural dimensions are reduced, and the number of its constituent mole- cules diminished. The process of nutrition essen- tially consists in the several solids receiving from the blood, as it circulates through them, a succes- sion of particles similar to those of which their structure is already composed ; and throwing off into the same circulating fluid such other particles as are destined to be removed from their texture. The process by which certain particles are sepa- rated from the blood, and appropriated to the structure of the solids, is termed assimilation ; and the process of detaching such particles as are no longer fitted to form an integral part of their structure, may be termed the process of dis-assimi- lation, or of interstitial absorption. On the equilibrium of these two processes the due nutrition of the solids essentially depends ; if either process preponderates, the balance of nu- trition is destroyed : if, for example, the powers of assimilation exceed those of dis-assimilation, the nutrition of the part becomes excessive ; but if, on the contrary, the powers of dis-assimilation pre- ponderate, the nutrition of the parts is diminished in proportion. When one or more tissues or organs are affected in the last mentioned way, they are said to be in a state of atrophy ; but when the affection is general, and the whole system partici- pates in the atrophy, the term marasmus, or emaciation, is more usually employed to express it For this reason we shall confine the following observations to cases of partial or local atrophy. The effects of atrophy vary considerably, ac- cording to the extent of the affection, and the tex- ture of the part affected. The atrophy, for instance, may be confined to one of the component tissues of an organ, the others still retaining their natural dimensions, or even acquiring an increased de- velopment; as in the peculiar alteration of the liver, described by Laennec as a new morbid pro- duction, under the name of cirrhosis ,• but which Andral has shown (Clinique Medicale, t. iv. p. 7.) to depend upon atrophy of the red, and hypertro- phy of the white, substance of that viscus. In this form of atrophy the organ affected may retain its natural dimensions, or may even increase in size, the atrophy of one of its tissues being more than compensated for by the hypertrophy of another. When the atrophy affects all the elementary tissues of the part, a proportionate loss of substance is necessarily produced. The membranous organs are rendered thinner, and this thinning of their tissue may even go on until it ends in their per- foration. The parenchymatous organs are dimin- ished in bulk, except in those cases where their internal structure becomes rarefied, as occurs in atrophy of the bones and lungs. We have seen the femur of an adult so atrophied internally as to float on the surface of water like so much cork, while externally it presented no appearance of any such alteration. The colour of an atrophied organ is usually paler than natural; it receives less blood, and is often so altered in its appear- ance as to retain few traces of its orginal organi- zation ; being in some instances almost wholly reduced to cellular tissue. In cases of extreme atrophy, the organ affected may be reduced to a mere rudiment, or may even disappear altogether. It is a curious fact that several organs, as they fall into a state of atrophy, frequently have a preter- natural quantity of fat deposited on their surface; and this deposition of fat is in general proportion- able to the extent of atrophy, and consequent diminution in the size of the organ. We have repeatedly seen the muscular parietes of the heart, especially those of the right ventricle, considerably reduced in thickness, and coated with a deep layer of fat: near the apex of the ventricle, this atrophy of the muscular, and hypertrophy of the adipose tissue is particularly remarkable ; the muscle being sometimes as thin as paper, and covered with a layer of fat nearly half an inch in depth. "Ana- logous phenomena are observed in certain circum- stances in the animal kingdom; where, in propor- tion as an organ decreases in volume, a fatty secretion is found to be deposited around it : thus in the spermaceti whale, and many of the fish tribe, an oily substance fills the very considerable space which exists between their diminutive brain and the parietes of the cranium."* There are some cases in which the atrophy of an organ may be regarded as a healthy or physiological process; as when parts, whose functions are no longer required in the economy, waste away or even disappear altogether. In the fcetus in utero the functions of the vesicula umbilicalis cease after the * Pathological Anatomy, translated from the French ol Professor Andral by Dr. Townsend and Dr. West. ATROPHY. 235 third month, and the organ itself disappears soon after; the membrana pupillaris likewise ceases to exist before the full period of foetal life is accom- plished. Other organs that seem to be essential in foetal life fall into a state of atrophy soon after birth; amongst such may be enumerated the ductus arteriosus, and venosus, and other blood- vessels used only in the foetal circulation ; the suprarenal capsules, the left lobe of the liver, and the thymus gland. Again, certain organs that are constantly employed in youth and manhood cease to be as actively employed in advanced life, and accordingly fall into a state of atrophy. The thyroid gland decreases in old age; the organs of generation, too, lose their natural size. M. Ribes has particularly described the alterations which the corpus cavernosum penis undergoes in old age : " the cells become larger, and the membra- nous septa that intersect its interior become thinner, and are even partially absorbed, so that quicksilver injections pass readily into it" (Bull de la Faculte, t vi. p. 299.) The ovaries and mammary glands are also, in advanced life, reduced to mere rudiments ; and in extreme old age every organ in the body falls into a state of atrophy ; the digestive apparatus being the last to share in the general decay. Andral states that atrophy, and consequent rarefaction of the parenchyma of the lung, is one of the most constant causes of the emphysematous condition of that organ so frequently observed in old age. " In the parts where this alteration exists, there are no longer to be found either bronchial ramifi- cations or vesicles properly so called, but merely cells of greater or less diameter, divided into com- partments by imperfect septa or irregular laminae. The portion of lung in this condition bears a per- fect resemblance to the lung of the tortoise tribe." (Op. cit) We have had repeated opportunities of verifying the accuracy of this description of the changes which the texture of the lung undergoes in advanced life. Tenon calculates that the osse- ous parietes of the skull lose one-fifth of their weight in old age. (Mem. de l'lnstitute, t. i. p. 221, an. vi.) M. Desmoulins found the brain in persons above seventy specifically lighter than at forty years of age; and its actual weight, he states, is diminished from one-fifteenth to one- twentieth of the whole : he likewise states, that in old persons of both sexes the trunks of the nerves, and their filaments, are considerably di- minished in size below their standard in the adult.* These phenomena of atrophy are still more remarkable in those animals which, during the progress of their lives, undergo certain metamor- phoses. Thus in the tadpole, when about to change into a frog, the tail gradually disappears, and the gills are obliterated, their place being supplied by lungs, which were in a rudimentary state so long as the animal retained the form of a tadpole and respired only in water. (Andral, Op. cit.) In all these instances the atrophy may be re- garded as a natural phenomenon, regulated by a general law in physiology—that all organs attain their maximum of development at that period * De l'Etat du Systeme Nerveux, &c. Journal de Phy- sique, t. ix. p. 442. when their functions are most exercised, and subsequently decline as their functions cease to be required in the economy. But we likewise find atrophy occurring under other circumstances, and constituting a true mor- bid alteration. Amongst the pathological causes of atrophy may be enumerated : — (a.) An original deficiency of development. From the science of embryology, which has been so successfully cultivated of late years, we learn that the formative process may be arrested at any period during the evolution of the foetus, so as to cause a total suspension in the development of any organ or set of organs ; in consequence of which the organ thus arrested in its development continues, up to the period of birth, either imper- fectly formed or altogether deficient; in fact remains precisely as it was at the period when its evolution was suspended. In this way are pro- duced the different varieties of congenital atrophy. In cases of congenital atrophy of the limbs, Rostan and other pathologists have seen the hemisphere of the brain on the side opposite the deformity converted into a serous sac, as if from having been early arrested in its development; and M. Serres states that when the cervical swelling of the spinal cord is deficient, the upper extremities are like- wise deficient; and that when the lumbar swelling does not exist, the lower extremities are invariably wanting. These observations would lead us to conclude that there subsists an intimate relation between the perfect development of certain organs and the perfect evolution of the nervous centres ; but, on the other hand, there are also facts which would lead us to infer that this relation is much less absolute than was for a long time supposed ; and that, under certain circumstances, all the different organs, as well as their nerves, may attain their full development, notwithstanding the deficiency of the nervous centres. Indeed, it has been fully proved in several cases of anencephalia and amyelia, that the nerves may be perfectly developed independently of the existence of the brain or spinal cord. From these cases it appears that the nerves are primarily formed in those organs which it is their office to connect with the centres of the nervous system ; and that they do not unite with those centres for a considerable time after their first rudiments are perceptible. (Andral, Op. cit.) (b.) A diminution in the usual supply of blood, arising either from a reduction in the whole mass of the circulating fluid, as in phthisis, tabes mesen- terica, and other diseases affecting the process of digestion and sanguification; or from any local obstruction to the arrival of arterial blood, as when the main artery leading to an organ is obliterated, or its caliber diminished: we have seen one of the kidneys in an adult as small as that organ usually is in the fcetus, and its blood-vessels proportionably diminutive. M. Lobstein records a case in which the spleen was no larger than a filbert, and the splenic artery so small as scarcely to admit a hair. In such cases, however, it is not always easy to determine whether the atrophy of the organ is in reality the cause or the effect of the atrophy of its artery ; for we know that the arteries accommo- date themselves to the size of the organ they are destined to support; increase with their growth, 236 ATROPHY. as in the pregnant uterus, and diminish with their diminution, as in the same uterus after delivery. (c.) A diminution in the nervous influence which regulates the movements, and presides over the powers, of assimilation and nutrition in the part. Thus in affections of the brain producing hemiplegia, we generally And the paralysed limb more or less wasted ; and in all cases of injury to the nerves, the atrophy of the part to which the injured nerve is distributed invariably follows. The degree of atrophy is not, however, always proportional to the degree of paralysis, nor even to the length of its duration. In some cases, para- lysed limbs become atrophied much more rapidly, and to a much greater degree, than in others. The cause of these differences it is not always easy to determine. It is probable that the various diseases of the nervous system which produce paralysis do not determine the atrophy of the paralysed limb solely by destroying the power of the will over the movements of the part, but that there likewise subsists a direct connection between the nutritive functions of the part, and the nervous influence which regulates its movements and inter- nal operations; so that the capillary vessels, which are the parts more immediately engaged in the process of assimilation and nutrition, being held immediately under the control of the nervous influence, are, consequently, directly affected by any derangement or modification of the nerves which exert this influence over them. But even admitting this hypothesis, it still remains to be determined whether this influence of the nerves over the process of assimilation is exerted by all parts of the nervous system indifferently, or by one class of nerves in particular. We have examined the paralysed limbs of a great number of individu- als, and have generally observed that in those cases where the paralysis arose from disease of the brain, the wasting of the paralysed limb occurred slowly, and was directly proportionate to the loss of motion in the part: whereas in those cases where the paralysis arises from an affection of the nerves of the part, the atrophy takes place much more rapidly, and is considerably greater than could be accounted for by the mere loss of motion. In several of the old and infirm paupers who have founcLan asylum in the Dublin House of Industry, and who have been hemiplegic for a number of years in consequence of cerebral disease, the wast- ing of the paralysed limbs is very inconsiderable, and indeed scarcely greater than would have oc- curred if the limbs had been voluntarily kept in a state of inaction during the same length of time. But in every case which we have had an oppor- tunity of examining, where the paralysis arose from an affection of the nerves of the part, the atrophy which ensued was exceedingly remark- able, even though the loss of motion in the part were only partial. In cases of unreduced disloca- tion of the humerus, the pressure of the head of the bone on the brachial nerves produces a remark- able atrophy of the arm, even though the limb retains a considerable degree of motion. Mr. Bell relates two interesting cases of atrophy arising from local disease of the nerves. In one, " the muscles and ball of the thumb were wasted, so that the bones and the strings of the tendons over them might be felt quite plainly." In the other, he says « whilst the fore-arm is firm to the feeling as you grasp it, the muscles of the arm are wasted and loose, so that you can feel all the processes of the humerus from its upper to its lower end ; the deltoid muscle is also quite gone." In comment- ing on these cases, Mr. Bell observes, (Appendix, p. 160,) "These affections of particular muscles, or classes of muscles, imply a very partial disorder of the nerves : a disease in the brain, or a disease in the course of a nerve, must influence the whole limb, or that portion of it to which the nerve or nerves are distributed. But in these cases, par- ticular subdivisions included in the same sheaths, or running the same course, are affected." Another example of the excessive wasting which occurs from affections of the nerves, is to be found in the paralysis which sometimes accompanies painter's colic. • We are acquainted with a gentleman whose arm was strained by an accident when he was a child y the injury was not attended to at the time, and the limb is now perfectly useless, and so wasted that it does not measure above one-third of the circumference of its fellow. M. Lobstein mentions a case somewhat similar. A man died at the age of fifty-four, with remarkable atrophy of his right leg, caused by a fall received when a child, by which the crural and sciatic nerves were severely injured. On dissection, all the soft parts and even the bones of the paralysed limb were found reduced to an extreme state of atrophy; the right femur weighed only three ounces two drachms and a half, whilst its fellow of the left side weighed nearly double. The gastrocnemius and soleus muscles of the sound limb weighed eight ounces, while those of the atrophied limb weighed only two ounces and six drachms. (Traite d'Anatomie Pathologique.) This excessive state of atrophy not unfrequently follows when the nerves of the part are affected, but, we believe, seldom occurs to the same extent in cases of paralysis arising from disease of the brain : in the latter case the power of volition, and consequently of voluntary motion, is destroy- ed, and the part becomes atrophied from inaction in the latter. Not only the power of voluntary motion is lost, but the nervous influence, which regulates the action of the capillaries, and directly controls the functions of nutrition, is likewise in- jured, and the atrophy of the part follows in pro- portion. It must, however, be admitted that fur- ther investigations are required to enable us to account for the great varieties we observe in the different degrees of wasting in paralysed limbs : it is probable that some additional light may be thrown on the subject by investigating whether the nerves of sensation or those of motion are more immediately connected with the function of nutrition. (d.) Another cause of atrophy is to be found in the diminished activity or total suspension of the natural functions of an organ. The effect of in- action on the muscular system has been already alluded to .- a similar suspension of function is found to produce the same effect on the internal organs, in accordance with the general law, " that the development of an organ is directly propor- tioned to the activity of its functions." When one of the double organs, as, for instance, the ATROPHY —AU AUSCULTATION. — In practical medicine, the term auscultation (from ausculto, to listen) is properly applied to all the methods used for dis- covering or discriminating diseases by means of signs having relation to the sense of hearing. It * One of the Editors was witness of a similar result in the case of a right reverend prelate, who died at a very advanced age, having suffered from the disease no- ticed in the text a great many years before his death. SCULTATION. 23T therefore comprehends the study of all sounds in- dicative of disease, in any part of the body, whe- ther produced naturally or artificially, and whe- ther perceived by the unassisted ear, or through the help of instruments. The following synopsis includes all the im- portant signs of disease recognised by auscultation. I. Signs derived from sounds produced natu- rally within the body. 1. The sounds having their origin or seat with- in the chest. a. Dependent on the motions of the heart. b. Dependent on the motions of the lungs in respiration. c. Dependent on the action of the vocal or- gans. 2. The sounds having their origin or seat with- in the abdomen. a. From the peristaltic movements of the intes- tines when containing air. b. From the pulsations of the foetal heart. c. From the movement of blood in the utero- placental arteries. 3. The sounds having their origin or seat in the arteries. II. Signs derived from sounds produced arti- ficially, within the body or on its surface. 1. The sounds produced by percussion of the surface. a. Of the chest. b. Of the abdomen. c. Of other parts of the body. 2. The sounds produced by succussion of the body. a. In the chest. b. In the abdomen. 3. The sounds produced by the friction of the parts of a fractured bone. 4. The sounds produced by the contact of solid instruments with calculi in the urinary bladder. It would seem, at first sight, most proper to treat first of the sounds naturally produced within the body. It will, however, be found more for the reader's advantage to notice previously the artificial sounds; because these are more simple and more easily understood, and because the knowledge of them will greatly facilitate the com- prehension of the more complex results of the method applicable to the recognition of the natu- ral sounds. For this reason we shall commence with those signs derived from percussion of the external surface of the body. Auscultation or sounds artificiallt pko- duceo within the bodx or on its sur- face. Percussion.—The application of percussion to the surface of the body, with the view of pro- ducing sounds whereby the physician might judge of the state of the subjacent parts, was first made about the middle of last century by Leopold Auen- brug, or Auenbrugger, a German physician, then residing at Vienna. This method, unquestiona- bly one of the greatest improvements ever made in physic, was announced to the world in a small volume, in Latin, first published in the year 1761. In his little work the author scarcely notices the principles upon which the method is founded, and gives us no insight respecting the circumstances attending its discovery. The new means of diag- lungs or kidneys, is incapacitated from acting, the other invariably acquires an increase of volume proportioned to its increased activity of function : the converse of this proposition is equally true, for when the functions of an organ are by any cause rendered less energetic than usual, it under- goes a proportionate diminution of volume. A remarkable illustration of this fact was observed by M. Renaud in the dissection of a monkey, and is described by Andral, (Op. cit. vol. ii. p. 456.) "An enormous ganglion, filled with tubercular matter, had so compressed the main bronchial tube of one of the lungs, that its cavity was al- most completely obliterated ; the lung to which it was distributed had undergone a remarkable de- gree of atrophy ; and the thoracic parietes of that side had contracted and fallen in, as in the case of absorption of a pleuritic effusion." The atro- phy of the testes in individuals who have lived in strict observance of their monastic vows, is a fact perfectly authenticated. Other instances might likewise be adduced, but these are suffi- cient. (e.) The last cause of atrophy to which we shall allude is inflammation. We frequently observe an attack of inflammation succeeded by a marked degree of atrophy, or even by the total oblitera- tion of the inflamed organ. In a soldier who had suffered from repeated attacks of hepatitis in In- dia, we found, on dissection, the liver reduced to one-fourth its usual size, and composed principally of condensed cellular tissue. Andral mentions a case of suppuration of the gall-bladder, opening externally, and discharging several gall-stones, in which after death no trace of the gall-bladder could be found on dissection.* Inflammation oc- curring in an artery or vein not unfrequently causes the obliteration of its cavity, after which it speedily degenerates into a ligamentous cord. Another mode in which inflammation sometimes produces the atrophy of an organ, is by the pres- sure exercised by the product of the inflammation. Thus we find the lung atrophied by the pressure of the purulent fluid in empyema ; and in chronic pericarditis the heart has been found corrugated on its surface, and greatly reduced in size. As to the treatment best adapted for the removal of this morbid alteration, the first object of the practitioner should be to ascertain on which of the causes above enumerated the atrophy depends, and, if possible, to remove it; for unless we re- move the cause, it will be in vain to attempt re- moving the effect; but when once the cause ceases to operate, the natural nutrition of the part will soon resume its wonted activity. It may, however, in general be promoted by such measures as are calculated to invigorate the system, exer- cise the functions, and sustain the temperature of R. Townsend. 238 AUSCULTATION. nosis, Inventum Novum, as he justly terms it, seems to have been received with slight consider- ation, both by his own countrymen and by for- eigners ; and its value was never fully recognised, much less established in the estimation of the medical profession, until the publication of Cor- visart's translation of the original work, in the year 1808. From this period, however, the prac- tice of percussion became general in France ; and it has since spread over every part of the civilized world. Its true value and importance were yet further established by the great analogous disco- very of Laennec in 1816; although this discovery was considered by many as calculated to super- sede the original method of Auenbrugger.* All bodies, on receiving a certain degree of im- pulse, are susceptible of having their particles thrown into a peculiar kind of tremor or agitation, termed vibration, which, when communicated to the auditory sense, constitutes sound. The inten- sity and permanency of this vibration differ great- ly in different bodies, according to the nature of the sounding body, its form, the manner in which the impulse is communicated to it, and the nature of the medium in which it is placed. The usual medium of sound to us is the atmospheric air, which receives the specific vibration from the sounding bodies, and conveys them to the ear. Air is, however, very far from being the best con- ductor of sound ; much less is it essential to the conducting of sound, as was formerly imagined. But as it is the usual medium between us and sonorous bodies, its relations to these become of the chief importance in every inquiry having refe- rence to the practical habitudes of sound. The following approximative statement shows the rela- tive conducting powers of different substances. It is its peculiar aptitude as an intermedium, not its actual powers of conducting sound, that gives to air a degree of practical superiority over all other bodies. Taking the conducting power of air as 1, the conducting power of iron and glass is as 16, of copper 11, of wood 10, of silver 8$, of water 4£. Percussion is one of the most com- mon excitants of sonorous vibration. The sounds produced by it will, of course, vary according to the circumstances above mentioned ; but the same body will always produce the same sound under similar circumstances. Upon this fact is founded the practice of percussion as applicable to the diagnosis of diseases. If we are acquainted with the qualities and circumstances which render bo- dies when struck susceptible of particular sounds, the sounds become signs of these qualities, and may be used as means of acquiring a knowledge of them. This principle is practically acted on, * Auenbrugger was born in Graets in Styria, in 1722. He graduated at Vienna, and afterwards became physi- cian in ordinary of the Spanish nation, in the imperial hospital of that city. In Ersh and Puchelt's Literatur der Medicin he is recorded as the author of two other medical works, relating to madness, one in Latin, pub- lished in 1776, and the other in German in 1783. In the same record Auenbrugger is stated to have died so late as the year 1809, in the 87th year of his age. The In- ventum Novum was first translated into French so early as the year 1770, by Roziere, but appears to have drawn little attention at the time. Corvisart's translation, as stated in the text, was published in 1809. The only Eng- lish translation of this work was published in 1824, with a selection of Corvisart's Commentaries, and additional Notes by the translator. See " Original Cases, &c., by Joan Forbes, M.D. London, 1831" in many cases, by artisans ; and might be applied by physicians to the recognition of the qualities of the internal parts of the human body, with much more effect, if the substances in the latter were as simple and distinct as those with which artisans have to do. There is, indeed, a funda- mental obstacle in the way of acquiring know- ledge in this manner, namely, the great difficulty of so cultivating the sense of hearing as to enable it to appreciate minute modifications of sound. But much more may be effected by practice, even here, than is commonly imagined. Carpenters and bricklayers are in the daily habit of applying percussion to the surfaces of bodies, with the view of enabling them to judge of the nature of the parts beneath, concealed by floors, walls, &c. In passing the hammer along the floor or wall of a room, they find no difficulty in ascertaining the place of every joist, puncheon, chimney-flue, &c. The soundness of a beam is ascertained in the same manner, and in the dark, as readily, and on the same principle, as the money-changer judges of the goodness of a coin. In these and all other cases, the qualities of the resulting sound, as has been already stated, depend no less on certain accidental circumstances of con- formation, medium, &c. than on the intrinsic con- stitution of the bodies struck. The same mass of clay will yield an entirely different sound when percussed, respectively, in a dry pulverised state, in a moist adhesive state, when converted into a solid mass by heat, when formed into a vase and baked. Of all the modifications of form of which matter is susceptible, that which we have supposed the mass of clay to assume in the vase, namely, a hollow body with thin elastic walls, and containing air, augments the sonorousness in the greatest degree. In this particular configuration of elastic bodies, the facilities of vibration of their particles, and the degree of their relations to the air, are both greatly increased ; and it is therefore suffi- ciently obvious why their degree of sonorousness is increased likewise. It is hardly necessary to adduce any exemplification of a fact which must be familiar to every one. We need only compare the sounds from a solid log of wood, and from the same log when hollowed into a pump, or box, or manufactured into a cask ; or these latter sounds with those from the same bodies when filled with any matter of greater density than air. Any diminution of the degree of elasticity of the con- taining solid, or in the quantity of the contained air, will diminish the degree of sonorousness on percussion. Every one is acquainted with the difference of effect in beating a drum or tambou- rine when braced and unbraced ; or a bladder when completely or only partially filled with air. Among the circumstances extraneous to the nature of the sounding body, which modify the sound elicited by percussion, the qualities of the body which percusses, and the manner in which the impulse is communicated, deserve attention. A stroke on a bell with an iron hammer and with a wooden mallet, will elicit very different sounds ; so will a blow with the pulpy extremity of the finger and a slap with the open hand, on the sur- face of the body. In applying percussion to the investigation of disease, we endeavour to prevent as much as possible all difference of result from AUSCULTATION. 239 those circumstances, by using a percussing body little susceptible of sonorous vibration, and by applying it in such manner as to excite this vibra- tion rather in the substance of the body struck than in the point of contact Our object is, of course, to judge of the qualities of the body struck, not of the body striking. The animal frame, like all other material ob- jects, is more or less sonorous when percussed, according to the nature of its component parts, their mass, degree of solidity, configuration, and their relations to the usual medium of sound, the circumambient air. Percussion of a fleshy part of the body, as the limbs, yields only a slight and dull sound ; percussion of a bone, as the tibia or skull, yields a much louder and clearer sound ; while percussion of a part that is hollow and con- tains air, as the chest, affords a yet louder sound, and one that is peculiar to bodies so circumstanced. As many diseases, by altering the density and other qualities of the body which influence the production of sound, necessarily alter the natural resonance, the modifications of sound discovered by percussion thus become means of detecting the presence, and appreciating the extent, of these diseases. The only parts of the body to which this mode of investigating disease has hitherto been applied with advantage, are the cavities of the chest and belly. Both of these afford particular facilities, from containing various organs of different den- sity, and having well-defined limits; from being hollow or containing naturally a certain proportion of air; and from the liability of this air to be dis- placed in disease, by matters of much greater density. The chest, from having solid, tense, and elastic walls, and from containing at all times a large quantity of air essential to its healthy state, possesses many and great advantages over the abdomen in admitting the application of this method of investigation. But even in the latter, the practice of percussion is far from being un- productive of important results; although a somewhat more elaborate method is necessary to obtain them.—(See Abdomen, Exploration of the.) Percussion of the chest.—On considering the anatomical structure and physiological actions of the human thorax and the organs contained in it, we at once perceive that this part of the body possesses, in the state of health, qualities, as to matter, form, and relations to the atmosphere, which ought to render it considerably sonorous when struck. It may, indeed, be not inaptly described as a sort of elastic box or basket of bones and cartilages, the interstices of the wicker- work being filled up by a thin layer of flesh, and the whole covered, both externally and internally, by a membrane of considerable density; the greater portion of the interior cavity being occupied by air diffused through the spongy texture of the lungs. In the state of health the lungs are always in close contact with the walls of the chest; and as their solid materials bear only a very small pro- portion to the space occupied by the air contained within them, the same results, nearly, are obtained from percussion of the external surface of the chest, as if its cavity were filled with air. We say nearly, because it will be seen afterwards that, in certain cases in which air exists loose in the cavity of the chest the sound resulting from percussion is then louder than in the state of health—proving that the substance of the lungs, however rare and porous, does impede the sonorous vibrations of the air contained within it As many of the diseases of this cavity mechanically exclude a portion of the air contained in it in the state of health, per- cussion on its surface will in such circumstances necessarily indicate the change that has taken place in the density of the parts within; just as a cask that yields one particular sound when filled with air, will yield another when filled with water or sand. Percussion may be performed either on the sur- face of the chest, or on any solid or tense body firmly applied to it. The former is termed direct percussion, the latter mediate percussion. We shall notice these in order. I. Direct percussion is the mode originally proposed by Auenbrugger, and has been univer- sally adopted until within these few years. It consists simply in striking the chest with the points of one, two, or more fingers pressed closely toge- ther, and observing the degree and quality of the sound thereby produced. The hand as well as the chest may or may not be covered ; the best plan, however, seems to be, to keep the chest covered and the hand bare. The blows should have considerable force, yet short of giving pain, and should follow in quick succession, the fingers being instantly raised from the chest, so that there may be free play for the elasticity or resiliency of the parts struck. A very few blows generally suf- fice in the same spot; sometimes a single blow is sufficient; but it is commonly necessary to repeat the operation over a considerable portion of the chest, if not the whole of it. In piactising percussion, the operator does not form his judgments exclusively from the nature of the sounds elicited. He judges equally from the tactual sensation communicated by the part struck, to the finger ; and it sometimes happens that this latter sensation is the more important of the two. For this reason a bystander can never be so good a judge of the state of parts percussed as he who operates. Percussion may be performed on any accessible part of the chest, while the patient is in any posi- tion ; but certain positions are preferable, and, indeed, necessary to obtain the full quantity of sound which any one part is capable of yielding. As the intensity of sound depends partly on the quantity of air, it follows that the results of per- cussion will be modified by the particular time, in the act of respiration, at which it is performed; and as we are always desirous of eliciting as loud a sound as possible, it is generally preferable to percuss during or immediately after inspiration, when the lungs are full; and not during or after expiration, when they are comparatively empty. In obscure cases, it is frequently necessary, or at least proper, to make the patient take a deep in- spiration, and then retain his breath for a few seconds, while we operate. Besides the presence of a certain quantity of air within the chest, it is essential to the produc- 240 AUSCULTATION. tion of the full sound, that the walls of the cavity be kept in as elastic a state, that is, as tense as possible ; just as it is necessary to brace tightly the parchment on a drum or tambourine before beating it With this view, we make the patient assume such positions as stretch the skin and muscles covering the walls of that portion of the chest we are going to percuss.* Accordingly, when practicable, it is desirable that the patient should be seated, and not lying down during the operation. If confined to bed, and able to sit up in it, he should do so ; if quite able to get out of bed, he should rise and be seated on a stool. When we operate on the fore part of the chest, we cause the patient to raise the head, and throw the shoulders forcibly back. When we operate on the back, we cause him to stoop the head downwards, and to cross the arms, so as to render the whole back rounded or arched. When we percuss the side, we desire the arm of that side to be raised above the head, and the body to be in- clined to the opposite side ; and, on the same principle, we are careful that the garment over which we percuss is drawn very tight across the part, and is kept in very close apposition with the surface ; and, by means of the fingers of the left hand, we can frequently not merely do this, but even aid the efforts of the patient to stretch the skin and muscular fibres beneath. In operating, we prefer to strike a bone, as the sound is greater than when we strike on softer and less elastic parte; but this is a rule which neither can nor should be always adhered to. A rule, however, which must never be forgotten or infringed, in percussing comparatively both sides, is to strike on similar substances, and, as nearly as possible, on exactly corresponding points, and also with the same degree of force, and under a similar angle. Inattention to any of these circum- stances is very apt to mislead beginners. It is also right for the student to be aware that not merely the posture of the patient, but his situa- tion relatively to other bodies, will modify the sound. Thus, bedding and bed-furniture, also carpets, and other bodies that deaden sound in general, will render that elicited from the chest less clear ; also the size of the room, &c.; just as is observable in the case of musical instruments. But, although it is well that the practitioner should not be ignorant of this circumstance, it can seldom materially affect our practical conclusions. II. Mediate percussion was only introduced into practice a few years since, by Mr. Piorry, a young physician of Paris, and differs chiefly from the foregoing in the employment of a small plate of ivory (named by him pleximeterj) laid flat upon the surface, upon which plate the percus- sion is made. If the bodies to which we apply percussion are hard, and more or less elastic, nearly similar results as to sound will be obtained, whether we apply the blows directly to their surface or to a thin plate of any solid and elastic substance laid upon them. In both cases, the character of the * This is less necessary in mediate percussion; indeed it is often proper, in this method, to keep the muscles relaxed.—Piorry, Du Procede Operatoire. 1830. t Measurer of percussion, from *\ifa, pircussio, and pirpov, modus. sounds elicited will depend upon the nature of the body under the part percussed. The degree of sound, however, will be considerably modified according as the body to be percussed differs much or little from the plate upon which the per- cussion is made. If the body differs little from the plate in solidity and elasticity, the sound will be nearly the same whether percussion is made on this or on the plate; but if the body is soft and inelastic, the difference of sound in the two modes of percussion will be very great When we apply percussion to a solid and elastic body, the sound elicited is the result, not merely of the direct primary impulse on the surface, but of the combined vibrations of the whole mass of matter beneath it. The primary sound immediately pro- duced by the blow will, therefore, be greatly mo- dified by the latter, and the modification, as ap- preciated by the ear, will be received as the one sound produced. But if percussion be practised on a soft and in- elastic surface, the impulse will not be propagated to the interior, and therefore will elicit no reso- nance from it In such a case, however, we have nothing more to do than to make a firm surface, by covering the part with a thin lamina of any solid, such as the plate of ivory before mentioned. This closely applied to a body becomes as a part of it, and the sounds easily elicited by percussion upon it, derive their character from the state of the subjacent parts. The firmness and tension of most parts of the thoraric parietes supersede the necessity of using a pleximeter on them; but some spots are covered with a considerable thickness of soft parts, and on these it is necessary for the proper exercise of percussion ; and the same may be said when the parts become thickened or painful from disease. In the percussion of the abdomen, possessed as it is of soft and yielding walls only, the pleximeter is absolutely necessary to the production of the requisite degree of sound; and it is yet further necessary, in many cases, in order to bring the superficial walls, by pressure, in contact with the subjacent parts. (See Exploration of thi Abdomen.) Mediate percussion alone may there- fore be said to be applicable to the investigation of abdominal diseases. It is at least equally ap- plicable with direct percussion to the chest; and as it has decided advantages in some cases, and no other disadvantage in any case than the ne- cessity of having an additional instrument, it ought to take precedence of the original method of Auenbrugger in the investigation of pectoral diseases also. The following are the relative advantages and disadvantages of the two methods, as stated by M. Piorry. 1. Direct percussion is often painful, particularly in unskilful hands; as when the blows are too forcible, when they are applied upon the soft parts between the ribs, or when the nails are prominent: even, in some cases, the degree of impulse necessary to produce sufficient sound excites either a sense of pain on the skin, or a painful jarring within the chest, occasionally lust- ing some time. The use of the pleximeter enables us to avoid all these inconveniences ; in the first place, because it defends the skin from the direct impulse of the fingers; secondly, because a less AUSCULTATION. 241 degree of impulse is necessary to produce the re- quisite sound ; and, thirdly, because the shock is much less felt from being equally diffused over a considerable space. Even in the case of recent vesications, the interposition of the plate will fre- quently enable us to employ percussion with little or no inconvenience to the patient. 2. As the walls of the thorax consist of very different ma- terials in different places, and vary likewise greatly as to their thickness, &c. direct percussion can only be effective when made on the more solid points of the thinner parts of the parietes; namely, the sternum, clavicles, ribs, and their cartilages : when made on the intercostal spaces, pectoral muscles, or mammas, it is both painful and inef- fective ; and when there is a great accumulation of fat below the skin, or the parts are anasarcous or emphysematous, the sound is still more imper- fect Mediate percussion will enable us to get over most of these difficulties. By means of the interposed plate we can percuss equally on the bone and soft parts ; and the precaution so requi- site in direct percussion to percuss on similar parts on both sides, becomes unnecessary, the plate constituting a sort of artificial solid wall to the soft parts. In the case of anasarca or emphy- sema, by compressing the distended parts with the plate, we obtain a solid point whereon to em- ploy percussion, and thereby obtain results other- wise unattainable. 3. Mediate percussion is much easier, and requires much fewer precautions than the ancient method. In direct percussion we must never lose sight of the rule that the percussion must be made precisely in the same manner on the two opposite sides of the chest, to enable us to deduce safe conclusions from the resulting sounds : for instance, the blows must be made on similar structures, with the same degree of force, under the same angle, &c. With the pleximeter these precautions are much less necessary, because we have here always the same flat smooth surface whereon to strike, and an artificial wall every- where of equal density and elasticity. Besides, less art is necessary in arranging the fingers in the latter case, a single finger being in general sufficient to elicit the necessary degree of sound. In admitting the validity of these advantages of mediate over direct percussion, we must allow that the superiority of either in practice will depend greatly on experience. By one well versed in direct percussion, an instrument will not often be needed in the exploration of the chest, as his experience will enable him to evade most of the inconveniences attending the former. The necessity of carrying an instrument, however portable, will be felt by some to be an incon- venience; but this can never be admitted as a reason for rejecting the employment of a method which possesses decided advantages. There is a variety of mediate percussion in common use still more simple than that of Pior- ry's, and which is well deserving the attention of the student This consists of the substitution of one or two fingers of the left hand for the plexi- meter,—the back of the fingers being uppermost. This proceeding possesses several of the advan- tages of M. Piorry's method; and it has even some few over it, exclusive of its greater simplicity. In cases where there is considerable emaciation, Vol. I. — 31 v M. Piorry's method is liable to mislead, unless the intercostal spaces are carefully filled with 6ome soft material; as, without this precaution, the sound may be modified by the hollow existing between the plate and the skin. Direct percus- sion on the ribs, or the employment of the fingers as a pleximeter. is often, in such cases, preferable. If we are careful in applying the fingers so as to make them fit accurately into the natural depres- sions, and thus form one body, as it were, with the thoracic parietes, — we are often enabled to use very forcible percussion without exciting pain, and also to elicit as definite sounds as by either of the other methods. This proceeding is free from another inconvenience which occasionally attaches to M. Piorry's method, especially in the hands of beginners. In the latter it sometimes happens that the loudness and sharpness of the primary sound arising from the contact of the two surfaces, are so considerable (particularly if the nail be used, which it ought never to be) as to drown, as it were, the secondary sound resulting from the modifying influence of the subjacent parts, from which modification it is that we form our judgment respecting the condition of those parts. When the fingers constitute the plexi- meter, we have little or none of this immediate clatter when the blow is given. [Various instruments have been devised for pleximetric percussion by Drs. Burne, Winterich, Bigelow, C. J. B. Williams, and others; (Dr. C. J. B. Williams, Lond. Med. Gaz., Dec. 16, 1842 ; and, Gerhard, Lectures on Diseases of the Chest, p. 21 : Philad. 1842) ; but, after all, for general purposes, the forefinger of the left hand, with the palmar surfaces to the chest, as men- tioned above, makes the best pleximeter. The sounds rendered will be more distinct if the patient holds his mouth open, whilst the chest is struck.] Whichever method we employ, it is of the utmost importance that the operator be fully ac- quainted with the relative sonorousness of the different parts of the chest in the state of health. This knowledge must be founded on an accurate acquaintance with the topographical relations of the external and internal parts, and can only be acquired by experience. In the article Explora- tion of the Chest, these relations are fully detailed. At present we can do little more than refer to it for information. We shall only here remark that the degree of natural sonorousness is, in all cases, dependent on th» anatomical structure of the external parts, and the nature and relative position of the organs placed beneath them re- spectively. The thinner and tenser the parietes, the greater the mass of the air-filled pulmonary substance beneath, and the closer it approaches the surface—the greater will be the natural reso- nance on percussion, and vice versa. A little practice on the healthy chest will make the stu- dent master of this subject; and he will find his progress much facilitated by the artificial plan in common use of mapping out the surface into dif- ferent regions. A knowledge of this plan will not merely fix more firmly and clearly the subject in his own mind, but will enable him much more readily to communicate his information to others. (See figures in the articles Abdomen and Chest, Exploration of the.) 242 AUSCULTATION Independently of th« relative sonorousness of different parts in the same chest, general differ- ences occur in different individuals, which it is not always easy to account for ; some chests be- ing very sonorous, and others comparatively dull. This might be expected, a priori, when the com- plexity of the structure of the contained and con- taining parts is considered. The greater or less degree of robustness, fatness, &c. has certainly an obvious effect; lean persons having always, ceteris paribus, more sonorous chests than those who are fat This is one reason why percussion fre- quently fails to detect the presence of tubercles in the lungs, the increase of sonorousness from the extenuation of parietes compensating for the aug- mented dulness of the viscus within. In children generally, the chest is very sonorous. This may partly arise from the small degree of development of their muscles, and the absence of fat; but it is probably, also, in part owing to the peculiar rela- tions of the lungs to the air, in this age. The sounds elicited by percussion from the chest in the state of health may be changed by disease in various ways,—in degree, in kind, and in their respective site. It is, however, necessary to be aware that many and important morbid conditions of the thoracic viscera occasion little or no alteration in the sound. This will be the case so long as the physical al- terations which attend the disease have not ma- terially affected the proportion of air naturally within the chest in a state of health. Thus, in bronchitis; in the first stage of pneumonia; in pleurisy attended by very slight effusion ; in that form of pneumonia termed interlobular, in which the moibid change may only occupy a small point in the centre of the lungs ; in the early stages of phthisis when the tubercles are disseminated through the pulmonary substance; in diseases of the heart and pericardium, without augmentation of size ; in nervous and neuralgic affections, &c.; there will either be no change in the sound, or the change will be so slight as to be appreciable by few observers, and consequently not to be generally admitted as a sign in practice. That there must, in reality, be a change in the sound in all the foregoing cases in which any change has taken place in the relative proportions of the solid and aerial matter naturally contained within the chest, cannot be doubted ; but as the natural imperfection or defective cultivation of our audi- tory sense prevents the detection of this, the result is practically the same as if no change existed.* The natural degree of resonance will be percep- tibly diminished whenever the proportion of air, usually existing in the lungs, is lessened by the addition of matters of greater density. The degree of diminution of the natural sound may vary from the slightest perceptible dulness to the completest deadness, or total abolition of the tympanitic re- sonance characteristic of the presence of air in a cavity. In the slightest degree, the dulness can- not be ascertained to be morbid from its actual but from its comparative amount; and an opinion will not, therefore, be formed respecting its cha- racter and indications, until after we have per- * M. Piorry scarcely admits the necessity of the quali- ications above mentioned: his experience and fact are, however, much beyond the ordiuary standard. cussed the rest of the chest, particularly the cor- responding parts of the opposite side. In the greater degrees of dulness, particu arly when amounting to the complete fleshy or dead sound, the simple percussion of the part suffices instantly to reveal disease. The morbid matters which take the place of air within the chest and thereby produce the diminution of sound, may exist either in the sub- stance of the lungs, or exterior to these. The following are the principal alterations within the substance of the lungs : hepatization in its differ- ent forms and stages; pulmonary apoplexy and oedema when of considerable extent; tuberculous degeneration or induration ; foreign growths dis- placing and compressing the pulmonary substance, such as cysts, melanosis, encephaloid tumours, &c. Exteriorly to the substance of the lungs are all the varieties of effusion or accumulation of liquid in the pleura; (pleurisy, hydrothorax, hsmathorax;) tumours of different kinds deve- loped in the cavity of the pleura or mediastinum ; diseases of other organs, such as hypertrophy of the heart hydropericardium, aneurism of the aorta, and even enlargement of the liver, &c. In the case of accumulation of liquid in the pleura, the dulness of sound may originate either from the exclusion of part of the air naturally contained there, or from the interposed layer of liquid pre- venting the transmission of the sonorous vibra- tions to and from the air in the lungs, on account of the different density of the media. The only cases in which the natural resonance of the chest is increased in disease, are dilatation of the air-cells (pulmonary emphysema of Laennec,) pneumothorax, and certain rare cases of tubercu- lar excavation. In all those instances the sound is increased because the natural proportion of air is increased, just as in the preceding instances it was diminished by the diminished proportion of the aerial contents. In emphysema, the morbid sonorousness commonly exists on both sides of the chest; in pneumothorax it is, we believe, al- ways confined to one side. The only form of tubercular excavation which considerably aug- ments the natural sonorousness, is that in which a cavity occupies the greater part of one lobe or two lobes, and contains but little liquid secretion. In cases of this kind the sound is sometimes a good deal altered in kind as well as in degree, having something of a metallic resonance, as if elicited from a flask or cup of metal. In the different articles in the present work which treat of the individual diseases of the chest, the practical application of percussion as a diag- nostic measure will be set forth at length : any detail on such points would, therefore, be super- fluous on the present occasion. Percussion of the abdomen. (See Abdomen, Exploration of.) Percussion of other parts of the body.—It does not appear that percussion of any other parts of the body beside the chest and abdomen is likely to lead to any results of value. In almost all affections of the limbs and external parts of the body, other modes of physical exploration, parti- cularly manual examination, will supersede the necessity of this method. The only cases in which it seems to offer any chance of being use- AUSCUL ful, are—tumours in the maxillary and frontal sinuses, and hernia. In the former cases, it is probable that a well-instructed ear would be en- abled, by mediate percussion, to ascertain whether the sinuses were empty or filled with solid mat- ter ; and in a case of hernia, no doubt a piece of intestine filled with air would yield a different sound from one filled with omentum. In doubt- ful cases, also, of swellings in the groin, this mea- sure might assist in discriminating an enlarged gland or other external tumour from hernia, cer- tainly from an intestinal hernia. But it can rarely happen to the surgeon to require assistance of this kind ; although the fact that the true diag- nosis has only sometimes been made on the ope- ration-table, shows that the proposal to seek aid from auscultation in such cases is not altogether absurd. Piorry asks whether in croup the larynx and trachea, which naturally yield a clear sound with the pleximeter, will not give a dull one when occupied by the false membrane of croup ! This seems probable, but what is the information worth ? Succussion.—This term is applied almost ex- clusively to a method of exploring pectoral affec- tions mentioned by Hippocrates. It consists in forcibly shaking the patient's body, and observing the sounds thereby produced. It has been also sometimes used in the investigation of abdominal diseases. There is only one class of cases in which this method can be productive of any re- sults, namely, where there is contained both a liquid and a gaseous fluid in an internal cavity : and the only instances in which such a combina- tion occurs are the following :—1. pneumothorax, in which there is an effusion into the cavity of the pleura both of liquid and air ; 2. a large tuber- culous cavity in the lungs containing also pus or other liquid, and air; 3. an accumulation of a liquid of any kind, and of gas, in the stomach or large intestines. The principle upon which the sounds are excited by succussion in those cases is sufficiently obvious : it is precisely the same as operates when we shake a bottle or bladder filled partly with water and partly with air. The rapid and forcible intermixture of the two fluids of dif- ferent density, and the impulsion of the heavier of the two against the walls of the containing vessel or part, give rise to the sound of fluctuation. In pneumothorax, this sound is frequently per- ceived in the most distinct manner; and as it is a pathognomonic sign of this disease, it becomes of great practical value. This sign was well known to Hippocrates, and is distinctly noticed in several parts of the writings that usually pass under his name. He appears, however, to have regarded it as a sign of simple empyema ; being unaware of the fact that the presence of air is absolutely necessary to the production of the sound of fluctuation. In empyema and hydro- thorax, no degree of succussion gives rise to any sound; as, indeed, must be evident to any one who regards the principle on which fluctuation depends.* * Many passages in the writings of Hippocrates prove that the practice of succussion must have been both a common and a successful means of diagnosis in the time of that phvsician. We can only, in this place, refer to •ome of these. We quote the edition of Vanderlinden: —De Morbis lib. I. v. torn. ii. p. 6. De Morbis lib. II. ATION. 243 Morgagni likewise notices the practice, but in a manner that proves his want of practical ac- quaintance with it. It is to Laennec that we are indebted for the true account of the principles on which it is founded, and for the just appreciation of its merits. As already stated, succussion is a most valuable sign in pneumothorax ; and as this disease is now known not to be extremely rare, there are no grounds (as Laennec observes) for leaving this method in the oblivion into which it has fallen. The mode of performing succussion is the same as practised and recommended by Hippocrates. The patient, seated in a chair or in bed, is to be quickly, yet not violently, shaken by the shoulder, the operator stopping the suc- cussion suddenly, and listening for the sound of fluctuation. In the proper cases this is heard most distinctly, and when so heard can never be mistaken for any thing else. We have heard it quite as distinctly'while the patient was in the act of rising or lying down. The cases of tuber- cular phthisis without pneumothorax, in which succussion produces the sound of fluctuation, are very rare. Laennec says he never met with but one case of the kind. The result can only be ex- pected when the excavation is extremely large, and contains a great quantity of pus as well as air. The sound of fluctuation in the stomach is very readily produced in many persons who have recently drunk much fluid, by the ordinary move- ments of the body. This becomes still more per- ceptible on succussion of the trunk. It has been attempted to apply this sign as a means of diag- nosis in disease of the pylorus ; but it is worthy of no consideration, inasmuch as there are many others greatly superior in certainty, and therefore in value. Auscultation of sounds artificially produced has been applied successfully to certain surgical dis- eases, particularly to the discovery of doubtful fractures and the detection of stone in the bladder. The nature of this work prevents any detailed account of cases of this kind : they are merely referred to on the present occasion with the view of directing the attention of the surgical student to the works which give an account of them.f Auscultation of sounds naturalli prv- duced within the body. This division of our subject is almost exclu- sively confined to the investigation of the sounds which originate within the chest; those having their site in the abdomen or elsewhere being of comparatively trifling importance. The remainder of this article will, therefore, be in a great mea- sure devoted to the consideration of the physical signs supplied by auscultation of the thoracic sounds. It is a singular fact that Hippocrates, upwards of two thousand years ago, endeavoured to ascer- tain the existence and nature of diseases of the chest by means of auscultation, that is, by the sounds produced by their presence within the chest. " You will know by this," he says, " that the chest contains water and not pus, if, on apply- xliv. torn. ii. p. 69. Ibid. xlv. p. 70. Coac. Prenot. torn. i. p. 565. De Locis in Horn. xxvi. torn. i. p. 379. Ibid. xxviii. p. 380. t See in particular Laennec, Aus. Med. torn. i. p. 117; Lisfranc, Mcmoire sur les nouvclles applications du ste- thoscope ; and Aleock's translation of the latter. 244 AUSCULTATION. ing the ear for a certain time to the side, you hear a sound like that of boiling vinegar." Many other passages in the writings that commonly go under his name, refer to the same means of detecting diseases. It hardly detracts from the merit of this great man, that, in the particular instance mentioned, his diagnosis is not true. Owing to a prohibition of dissecting dead bodies, which existed in his time, it was scarcely possible to be accurate in such a case. The merit of the discovery of aus- cultation, or, at least, the merit of having first at- tempted to discover diseases of the chest by means of auscultation, is unquestionably his ; and the chief object of the present article is to show to what a wonderful degree of usefulness this discovery was subsequently carried by a kindred genius, two-and-twenty centuries after it was first made. It would appear that the practice of auscultation in any of its forms, as employed by the Asclepia- des, had almost entirely fallen into disuse, and even oblivion, with modern physicians, until a very recent period. Laennec informs us that, previously to the discovery of the stethoscope, he himself, Bayle, and others, were in the habit of applying the ear to the side in studying diseases of" the heart; and we learn from a work of M. Donble, published two years previously, that this physician was accustomed to employ the same means in exploring diseases of the lungs. Speak- ing of the signs furnished by respiration, and of the sounds produced by it within the chest in dis- ease, he says that, with the view of hearing them more distinctly, " we must apply the ear closely to every point of all its aspects; by which means we can distinguish not merely the kind and degree of the sound, but even its precise site." lie adds, " I have frequently derived great benefit from this mode of investigation, which is peculiar to myself, and to which I was naturally led by the employ- ment of the like method in exploring the pulsation- of the heart." * Long before this period, indeed, one of our own countrymen, not of the medical profession, and who, in all probability, was unac- quainted with the writings of Hippocrates, was fully aware both of the existence and great im- portance of internal sounds as a means of diagno- sis, and, as Dr. Elliotson well observes, seems almost to have prophesied the stethoscope. We quote the passage as extremely curious in the lite- rary history of auscultation. " There may be a possibility," says Hook, " of discovering the inter- nal motions and actions of bodies by the sound they make. Who knows but that, as in a watch we may hear the beating of the balance, and the running of the wheels, and the striking of the hammers, and the grating of the teeth, and multi- tudes of other noises ;—who knows, I say, but that it may be possible to discover the motions of internal parts of bodies, whether animal, vegetable, or mineral, by the sound they make ; that one may discover the works performed in the several offices and shops of a man's body, and thereby discover what engine is out of order, what works are going on at several times, and lie still at others, and the like." " I have this encouragement not * Semeiologie Generate, par F. J. Donble, torn. ii. p. 31. Paris 1817. to think all these things utterly impossible, though never so much derided by the generality of men, and never so seemingly mad, foolish, and fantas- tic ; that, as the thinking them impossible cannot much improve my knowledge, so the believing them possible may, perhaps, be an occasion for taking notice of such things as another would pass by without regard as useless. And somewhat more of encouragement I have also from experi- ence, that I have been able to hear very plainly the beating of a man's heart; and it is common to hear the motion of the wind to and fro in the guts and other small vessels : the stopping in the lungs is easily discovered by the wheezing." « As to the motion of the parts one among another—to their becoming sensible, they require either that their motions be increased, or that the organ be made more nice and powerful to sensate and dis- tinguish them as they are ; for the doing of both which, I think it is not impossible but that in many cases there may be helps found." (Hook's Posthumous Works, p. 39, et seq.) There is no reason to believe that Laennec was acquainted with these opinions of the English philosopher; nor, if he had, would this know- ledge, any more than that which he derived from the writings of Hippocrates, have greatly detracted from his merits as the discoverer of mediate aus- cultation, and the inventor of the stethoscope. This great man was born in Bretagne, in France, in the year 1781, and early devoted himself to medicine. He commenced his studies in Nantes, and proceeded to Paris in the year 1800, in order to complete them. He there fol- lowed up his professional pursuits with all the enthusiasm of genius; devoting himself more especially to the investigation of the nature and signs of disease, in imitation of his master, Corvi- sart. Under the guidance of this great physician, he became a zealous and successful investigator of chest-diseases, by means of percussion ; and, while he proved its full value, he soon became sensible of its imperfections, more especially in diseases of the heart In cases of this kind, young Laen- nec and several of his fellow-pupils were accus- tomed, in imitation of Hippocrates, to apply the ear to the chest, in the hope of thereby aiding their diagnosis. He informs us that from these trials he derived little practical benefit; but it was from them that he was led to a discovery of the very greatest importance. This was the discovery of mediate auscultation; his account of which we shall give in his own words: " In the year 1816," he says, " I was consulted by a young woman affected with the general symptoms of diseased heart, and in whose case percussion and the application of the hand were of little avail, owing to her being extremely lusty. The immediate application of the ear being inad- missible for obvious reasons, I happened to recol- lect a simple and well-known fact in acoustics, and fancied it might be turned to some use on the present occasion. The fact I allude to is the great distinctness with which we hear the scratch of a pin at one end of a piece of wood on applying our ear to the other. Immediately, on this sug- gestion, I rolled a quire of paper into a kind of cylinder, and applied one end of it to my patient's chest, and the other to my ear, and was not a little AUSCUL surprised and pleased to find that I could thereby peTceive the action of the heart in a manner much more clear and distinct than I had ever been able to do by the immediate application of the ear. From this moment I imagined that means might be found to ascertain the character, not merely of the action of the heart, but of every species of sound produced by the motion of all the organs within the chest" (De I'Auscult Med. torn, i.) With that intuitive glance into the latent capa- cities of things, which only belongs to inventive genius, Laennec at once foresaw the great outlines of the discoveries which were afterwards evolved by his persevering industry ; and he set to work with a zeal and enthusiasm worthy the great ob- ject he had in view, and with a degree of success and fertility of results much more remarkable than the discovery itself. At this time he was physi- cian of the Necker Hospital in Paris; and he forthwith instituted in its wards a series of observa- tions and experiments on the new method of diagnosis, which were hardly interrupted for one single day, until the discovery may be said to have been almost perfected in his own hands. He first gave an account of his method to the Academy of Sciences, in 1818, and, in the following year, he published his immortal treatise " De I'Auscul- tation Mediate et des Maladies des Poumons et du Coeur." In announcing this work, he boasted that " he had been enabled to discover a set of new signs of diseases of the chest, for the most part simple, prominent and certain, and calculated, perhaps, to render the diagnosis of these diseases as positive and circumstantial as that of many affections which come within immediate reach of the hand or instruments of the surgeon." And it must be allowed that this boast is in a great measure justi- fied by the wonderful precision introduced by him into this department of medicine. The first object of Laennec after his discovery, was to improve and perfect the rude instrument he had used in his primary explorations; and, after many trials, he finally invented and adopted that which is now in general use. This instru- ment he denominated the stethoscope, (from o-ttj- Oos, pectus, and axoiriw, exploro.) It is now so well known that it is unnecessary to give any description of it. On a future occasion, we shall have to notice the principles on which it is con- structed, (see Stethoscope;) but before we can comprehend these, or the manner of using it, it is expedient that we should be made acquainted with the nature of the sounds which it is intended to convey to the ear. As every form of matter is susceptible of the vibrations which, when falling on the ear, give the sensation of sound; and as the motion of most bodies, when accelerated to a certain degree, excite these vibrations either in themselves or contiguous substances, it might be expected, a priori, that the thoracic organs, being in constant motion, should, in the performance of their functions, give rise to sound; and that they have been observed to do so, at least when diseased, is sufficiently evinced by the existence in all languages of such expres- sions as " wheezing on the chest,"—" rattle in the throat,"—"hearing the heart beat," &c. But no v* ATION. 245 attempt was made to classify or analyze the sounds before the time of Laennec. The motions that naturally take place within the chest are those of the lungs and heart, in per- formance of the functions of respiration and the circulation of the blood ; and both these give rise to audible sounds of various kinds and in different ways. From what we know of the effects of currents of air in producing sound when passing through narrow channels, or when partially impeded and interrupted, as by the branches of a tree, for ex- ample, we should expect that the incessant passage of air through the tubes and cells of the lungs, together with the constant dilatation and collapse of these, would be productive of very audible sounds, if the ear could be brought sufficiently near their source. At first, indeed, we might be led to consider them as altogether cut off from our auditory sense by the solid barriers of the chest; but when we come to reflect that the surface of the lungs is always, necessarily, in close contact with the inside of the walls of the chest, and that these walls are only from a quarter to half an inch thick, and consist of substances favourable for the transmission of sound, we are at once prepared to expect that the sounds in question may be audible through the thoracic parietes : and such is the fact. If we place our ear in close contact with the chest of any person while breathing, more particularly a child, we can distinctly hear sounds, synchronous with inspiration and expiration, on every part of the surface that lies over the lungs. Although sufficiently audible, these sounds are still only feeble in degree; and emanate, with nearly equal intensity, from almost every point of the surface of the chest. It is these qualities of comparative feebleness and equal diffusion over the chest, that prescribe one of the uses and forms of the stethoscope—that, namely, in which it ful- fils the office of a common ear-trumpet In this case, the instrument consists of a cylinder of wood, perforated longitudinally by a bore of nearly the same size as the auditory canal, and swelling out at the farther extremity into a funnel-shaped exca- vation, like the extremity of a clarionet or bugle. When this is placed upon any part of the surface of the chest, the ear, applied to the other extre- mity, will receive the whole of the respiratory sounds emanating from that portion of the chest included within its circumference—the sonorous vibrations, or rays of sound, (if we may be allowed the expression,) being concentrated by the fun- neled extremity, and conveyed along the tube to the ear. An instrument of this kind, then, is the best for exploring the sounds produced by respira- tion simply, whether in health or disease. But Laennec found sufficient reason, in his progress, to modify this, the simplest, and for respiration the best, form of the stethoscope. In following up his researches, he discovered that the sounds produced by the voice within the chest are of great importance as signs in several forms of disease; and he ascertained by experi- ment, that the particular sounds which are of most value, are best conveyed to the ear by a cylinder perforated by a bore of an equal caliber throughout In order to avoid the multiplication of instruments, 246 AUSCULTATION. (a thing always to be avoided when practicable,) he conceived that the same trumpet-shaped cylin- der might be made to answer the requisite end, by having fitted to its wider extremity a moveable plug, of the same materials, traversed by a perfo- ration of the same diameter as that of the upper portion of the instrument. And he found, on trial, that this answered perfectly. The only other organ within the chest, which, in the performance of its natural functions, pro- duces audible sounds, is the heart. These sounds, as every one knows, are very perceptible by the naked ear when placed in contact with the sur- face of the chest on the left side. There still ex- ist doubts among physiologists as to the precise cause of these sounds, and many different theo- ries have been promulgated with the view of ex- plaining them. Some account of these explana- tions and opinions will be given in the sequel. It is sufficient for our present purpose to observe, that in the exploration of the heart, a solid cylin- der is preferable to a tube, because we here require to judge, not merely of the sound, but also of the shock or impulse communicated to the walls of the chest; and for the conduction of impulse, a solid body is obviously superior to a mere tube. But here, again, the wish of avoiding the multi- plication of instruments led the inventor of the stethoscope to be contented with such a form as was found practically sufficient, though not theo- retically the most perfect, for the exploration of the heart—namely, the cylinder with the infixed plug or stopper, such as is used in the exploration of the voice. In the common form of the stethoscope, then, we possess an instrument suited for the explora- tion of all the sounds produced within the chest; and we may remark, that so long as the funda- mental principles on which it is constructed are attended to, its external configuration is compara- tively of little moment The manner of using the stethoscope is ex- tremely simple. The only precautions necessary are, to keep its pectoral extremity always in exact contact with the surface on which it rests, and to preserve the auditory canal of the ear in accurate communication with the perforation in the instru- ment. With the view of ensuring its more per- fect apposition, the hand that holds the instrument is kept close to its further extremity, in such man- ner that the little and ring fingers may be employ- ed as tentacula, or feelers, in regulating its appli- cation. A reference to the principles of its con- struction will point out the absolute necessity of keeping the whole of its pectoral extremity in contact with the surface ; and on this account it must never be inclined from its perpendicularity to the surface of the chest in order to accommo- date the convenience of the operator: the ear must be moved to suit the instrument, not the in- strument to suit the ear. The stethoscope may be applied either to the naked chest or over the clothes; as it is found that a moderate thickness of a body of the den- sity of cloth has only a very inconsiderable effect j in diminishing the intensity of the sounds. In certain cases, indeed, as in very lean and deform- ed subjects, it is quite necessary that the part we are examining should be covered, in order to give to the instrument that perfectly smooth and level resting-place so essential to its proper action. In some cases of this kind it is even necessary to apply small compresses of linen in order to fill up inequalities. As during percussion, and, indeed, more so than in that case, there must be no noise in the patient's chamber or its immediate vicinity during our ex- ploration with the stethoscope. At least, this pre- caution is necessary for beginners; although the ear that is accustomed to the sounds, will learn to catch them amid others that are much louder, just as various artisans accustomed to live amid the noise of machinery, are able to converse without any great elevation of voice. A very few words suffice to state in what way the stethoscope becomes, in the hands of an ex- pert auscultator, the means of an accurate diag- nosis. By it we learn that the motions of the lungs and heart, in a state of health, produce cer- tain determinate sounds in certain parts of the chest; and that these sounds are modified in cer- tain determinate ways, and certain other determi- nate sounds superadded, in states of disease : by the study of the symptoms during life, by dissec- tion after death, and by considering the principles of the generation of sound, we are able to connect, as cause and effect, particular forms of disease with particular sounds ; hence the indications of the stethoscope, in certain diseases, become posi- tive physical signs of these diseases. We shall occupy the remainder of the present article in illustrating this proposition, which in- volves the whole doctrine of auscultation as a means of diagnosis. Auscultation of the Respiration. I. Of simple respiration, natural and morbid. ^-The sound of healthy respiration, as discovered by the stethoscope, is somewhat different in differ- ent parte ; having one character in the pulmonary cells, another in the larger bronchial tubes, and another in the trachea. The common character of all these may be said to be that of a prolonged hiss or puff—such a sound as is produced by blowing forcibly into or through a small opening, and not very unlike the blast from the nozzle of a pair of bellows. That which originates in the pulmonary cells (and which may be denominated pulmonary, cel- lular, or vesicular,) is perceptible, in health, over every part of the chest with which the lungs are in contact It is such as we might expect to be produced by the rapid passage of air through a congeries of minute lubes and cells, composed of a thin and moist membrane ; viz., a low monoto- nous sound, almost exactly like that of a person breathing through the nostrils in a placid sleep, only feebler. It is a double sound; or rather there are two sounds ; the one corresponding with inspiration, the other with expiration; and the former is usually much stronger than the latter. We may produce sounds artificially, or may ima- agine sounds more or less resembling this; but, of course, it must be heard in order that a perfect idea of it can be communicated to the mind. And this is best done, in the first instance, by the ap- plication of the unarmed ear to the chest of a child, as the sound is naturally louder in children. We rocommend the naked ear in the first instance, AUSCULTATION. 247 because it requires some little practice to use the stethoscope, and because the mere application of this to the ear occasions a rustling noise, which might possibly be mistaken by the student for the eound he is in search of. When once heard dis- tinctly, this can never be mistaken. The sound produced in the trachea and larger bronchi is, as formerly mentioned, somewhat dif- ferent from that produced in the pulmonary cells; although it is not easy to describe the difference. In the pulmonary or cellular respiration already noticed, there is a character of slight crepitation, or roughness, as if from accompanying moisture, which is wanting in the bronchial and tracheal kind; and these latter, likewise, convey the impression as if they originated in a larger space. The prin- cipal difference between the tracheal and bronchial respiration consists in the idea of larger caliber being suggested by the former. In a state of health, the bronchial respiration can only be heard in the very largest bronchi. It is only by experience that we can acquire a perfect knowledge of the sounds of healthy respi- ration ; but having once acquired this knowledge, it becomes easy to discover when this natural cha- racter is changed. This change only arises from disease ; and it is the great object of the practical auscultator to detect the morbid sounds, and to trace them to their causes in physical changes of structure within the chest It has been already said that, in the state of health, the sound of pulmonary or cellular respi- ration is perceived over every part of the chest with which the lungs come in contact We are thus enabled, in the living body, to trace the boundaries of these organs with the greatest accu- racy. These boundaries, generally speaking, are the same as are indicated by the circumscription of the sonorous sphere in the trial of percussion. As in the case of percussion, also, the intensity of the sound varies in different parts of the chest; and the relative intensity of the sound in different parts generally corresponds in both forms of ex- ploration, the respiratory sound being loud where that of percussion is clear, and vice versa. Ac- cordingly, we may state the following to be the parts where the respiratory sound is perceived the most readily and most constantly : the axilla, the top of the shoulder above the clavicle, the subcla- vian region before, and the subscapular region be- hind. In general, the respiration is loudest on the anterior parts of the chest When the respiratory sound is perceptible over all its natural sphere, and with its natural charac- ters, we may be assured that there exists no dis- ease within the chest which materially affects the lungs; we may be certain, at least, that the air- cells are neither obstructed by fluids poured into them, nor by compression from without. When the natural sound is altered, or no longer exists, we may be assured that disease is present. [It is important to bear in mind, that difference of sentiment exists as to the comparative inspira- tory murmurs of the two sides under the clavicles, which are the common seat of tuberculous forma- tions. It has been asserted by Dr. Gerhard (Lec- tures on the Diagnosis, Pathology, and Treat- ment of Diseases of the Chest, p. 29 : Philad a. 1843,) that the bronchial respiration is decidedly j more distinct in the right lung than in the left, especially at the summit; and he accounts for it by the greater diameter and straighter course of the tubes at the summit of the right lung, which are not lengthened and curved as on the left side by the presence of the arch of the aorta. On the other hand, M. Fournet is satisfied, that in per- sons presenting all the characteristics of healthy lungs, the sounds of inspiration and expiration are precisely identical in all corresponding points. In the few persons in whom he detected a slightly greater development of the expiration under the right than the left clavicle, there were motives for a doubtful opinion respecting the state of the lungs. M. Fournet thinks, from the physical condition of the two lungs, that there is no reason why they should furnish different respiratory sounds. Last- ly, Dr. Stokes (on Diseases of the Chest, Dubl. 1837,) dwells especially on the importance of the discovery made by him, that in many persons there is a natural difference between the intensity of the murmur in either lung, and in such cases, with scarcely an exception, the murmur of the left is distinctly louder than that of the right lung. It would appear, consequently, and such is the result of our observation, that at times there is no marked difference between the two sides ; that at others the intensity of the respiratory murmur is greater on the right side ; and at others, again, on the left (Practice of Medicine, edit cit. i. p. 220.)] The natural sound of respiration may be weaker or stronger; it may be absent altogether ; and it may be complicated with adventitious sounds. 1. If the sound be weaker than natural in any one part, we may suspect that there is some or- ganic alteration in that part disturbing the healthy process of pulmonary expansion; that is, that there is either slight condensation of the vesicular structure of the lungs, or partial obstruction of the bronchi leading to that part, or slight displace- ment of the lung from the walls of the chest If the feebleness of the respiratory sound be general, however, we are to consider it rather as depend- ing on some natural peculiarity of constitution than on any disease of the lungs. And we may stale generally, that mere feebleness of sound, even when existing partially, is not much to be depended on as a sign of disease ; when combin- ed, however, with certain other qualities of sound, (as it commonly is,) it becomes of much more value. As we found, in respect of the degree of resonance on percussion, that there are great na- tural differences in different individuals; so it is with regard to the degree of the respiratory sounds. But there is no connexion between these peculiar- ities ; as we frequently find the chest very sono- rous when the respiratory sound is feeble. It is likewise highly necessary that the student should be aware, that the degree of respiration is liable to be greatly altered by various temporary causes, In many persons, the first application of the stethoscope produces such a degree of ner- vousness as to render the respiration hardly audi- ble for a few minutes; and it is only by waiting until this state has subsided that we can ascertain the real character of the respiration. In others, who are not nervous, the habitual sound of respi- 248 AUSCUL' ration is so feeble that it can hardly be perceived in the ordinary mode of exploration, even after a considerable time ; and if the patency of the air- cells were not proved by some additional trials, serious mistakes in diagnosis might be the conse- quence. The natural suggestion, in such cases, is, to cause the patient to breathe quicker or breathe deeper ; and this sort of artificial respira- tion, particularly the quick breathing, has often the desired effect of rendering the respiratory sounds sufficiently audible. Sometimes, however, these attempts fail; and it is necessary to have recourse to others. The most effectual are the various efforts which produce a great want of air in the lungs, either by expelling an unusual quan- tity of this fluid, or by retaining it much longer than usual. For this purpose we desire the pa- tient to cough, to repeat a long sentence aloud, or to count as many numbers as he can without drawing breath; or we desire him to retain his breath as long as he possibly can : in any of these cases we frequently find that the inspirations im- mediately succeeding the forced efforts become most distinctly audible in all the points of the chest where they had been not at all or very slightly perceptible before. We must never, therefore, conclude, from a single and hurried application of the stethoscope, that the lungs are impermeable because we do not at once detect the sound of respiration. 2. It has already been remarked that the sound of respiration is naturally much louder in children than in adults. This state continues until about the twelfth year. What may be the precise cause of it is not ascertained ; but that it is connected, at least with greater activity of the organ, seems to be almost proved by the fact, that whenever in adults any portion of the lungs is called upon to perform more than its wonted share in the respi- ratory act, that portion immediately yields a sound as loud as that of the child's lungs. Hence respi- ration of this kind, when observed in the adult, is termed puerile. In some few cases we find this loud respiration existing over, the whole lungs, and then it helps to characterise certain forms of dyspnoea. But, in general, it is found only in a part of one or both lungs, or in one whole lung ; and in this case it may be considered as almost a sure sign that the remainder of the organ is ren- dered incapable of performing its functions, from internal obstruction or external compression of its cells. Accordingly, we find this partial puerile respiration a constant concomitant of pneumonia, pleurisy, hydrothorax, and all other diseases which curtail the healthy proportions of the organ of respiration. When we observe this puerile respiration in adults without immediately disco- vering any physical cause for it, (as sometimes happens,) there are several morbid states of the lungs which we may suspect It is sometimes owing to the dissemination of tubercles through lungs otherwise healthy ; sometimes to partial lobular peripneumonies deeply seated in the lungs. Occasionally this condition of the respiration exists without any organic disease of the lungs, and can then be attributed to a nervous cause only ; and at times it is caused by disease of the heart, with no other affection of the lungs except that which Iaiiuh. arises from functional disorder of the circulation in them. 3. Various morbid conditions of the organs . within the chest may prevent the sound of respi- ration from being, in any degree, perceptible on the surface. The air may be prevented from en- tering the pulmonary cells of a part of the lungs, although these cells are perfectly sound, by the temporary occlusion of a large- bronchial tube by tenacious secretions, as in the case of a catarrh or common cold affecting the lungs. Here the sound of respiration is wanting, because the air-cells are inactive; and here percussion will afford a good sound. While the bronchi are free for the pas- sage of air to the air-cells, the cells may be entirely filled up by fluid or solid matters, and therefore incapable of admitting any air : this happens in inflammation of the lungs, and in some other cases; here percussion will elicit a dull sound. The lungs, although sound, may be removed from their natural situation in contact with the walls of the chest, by the interposition of matters of a solid, fluid, or gaseous character, poured into the cavity of the chest As these matters will act in the same way, viz. by at once compressing the air-cells, and separating them from the walls of the chest, they will all equally destroy the respi- ratory sound ; but they will furnish very different results upon application of the test of percussion. For instance, in the case of solid or liquid effusion, the sound will be quite dull; while, in the case of gaseous effusion, it will be louder than natural. The diseases that separate the lungs from the thoracic parietes are pleurisy, acute and chronic, hydrothorax, pneumothorax, &c. These, and many other cases, show the necessity of combining the use of the two methods in practice. They mutually throw a light on the indications of each other, and thus stamp a double value on our signs. By these we are enabled to discover instantly, and with the utmost facility, several most important diseases, which must otherwise often elude the skill of the best informed and most clear-sighted practitioner. 4. It was stated that the peculiar sound pro- duced by the passage of the air in the bronchi, termed bronchial respiration, is not audible in the state of health, except occasionally over the track of the very largest branches. No doubt this sound always exists in the bronchial tubes scattered throughout the lungs ; but in the state of health it is rendered imperceptible, partly on account of the bad conducting powers of the spongy texture of the lungs, and partly from its intermixture with the more general sound caused by the expansion of the air-cells. When, however, the vesicular respiration is obstructed by disease, either by the obstruction or compression of the air-cells, (as in inflammation of the lungs or pleura,) we then hear distinctly the characteristic sound of bron- chial respiration, even in the tubes of middling caliber. This variety of respiration becomes, there- fore, an important sign in certain diseases. There are several varieties of the morbid bron- chial respiration which deserve notice, and which the student will find described at length in the works of Laennec and Andral. In the more com- mon variety, the sound resembles an intense de- AUSCULTATION. 249 gree of puerile respiration, and it might be mis- taken for this if percussion over its site did not give the dull sound. At other times it Tesembles the noise made by blowing into a quill; and, occasionally, exactly resembles the brief, brisk puff used in blowing out a candle. There is yet another variety of morbid respiration, which, if not actually bronchial, belongs at least to the same class. This is the variety named cavernous by Laennec. It would appear sometimes to exist (or a sound very like it) in the case of dilated bronchi; but its general site and source is a morbid exca- vation in the pulmonary substance, arising almost always from dissolved tubercle. In these cases there sometimes exists the most perfect illusion of blowing into the ear through the stethoscope during expiration; while the air seems drawn from it during inspiration. This sign with its accompanying rhonchus (which will be noticed hereafter) is a most important sign in phthisis. [The sound of expiration becomes, at times, prolonged, and, like the inspiration, may be ma- terially altered in character. The altered expi- ratory sound was first urged as an important ele- ment in the diagnosis of the earliest stages of tuberculosis of the lungs by Dr. Jackson, Jr., of Boston. Prolonged expiration is, likewise, a . physical sign of emphysema of the lungs; and the writer has observed it in auscultating between the scapulae, when he has had reason to believe in the existence of dilatation of the bronchia only ; and occasionally he has heard prolonged expiration apparently as a natural condition. Dr. Walshe, indeed, (The Physical Diagnosis of Diseases of the Lungs, Amer. edit, p. 194, Philad. 1843,) remarks, that too few observers seem to be aware, that under whatever circumstances obstruction exists to the free circulation of air in the lungs, the expiration will be prolonged ;—" an obstruc- tion, which (experience shows) never acts on the duration of the sound without affecting some of its other properties." M. Fournet states, that alterations of character of bronchial respiration always set in with the expiratory murmur, and only affect the inspiration secondarily. With this statement, Dr. Walshe says his own experience accords, in regard to chronic maladies. He believes it to be correct, also, in the very great majority of cases of acute alteration of the paren- chyma of the lungs, as in pneumonia; and he thinks it probable, that in the few exceptional cases, in which a bronchial character has been detected in both murmurs simultaneously, the expiration may in reality have suffered first, " and the period of its isolated affection been so short as to prevent its being observed."] II. Of adventitious sounds connected with respiration. Besides varieties of intensity, the respiration may be altered by the admixture or addition of sounds which do not exist in the state of health. These adventitious sounds may origi- nate either in the bronchial tubes, or in morbid states of the parts exterior to the substance of the lungs. A. The sounds of the first class are by far the most important They are produced by the pre- sence of some morbid secretion within the air- tubes or pulmonary cells, or by some physical alteration of the coats of these. From one variety Vol. I. —32 of these sounds, audible by the naked ear, and termed, in popular language, 'the rattle in the throat,' or ' the dead rattles,' the whole have been classed by Laennec under the name of the rattle— in French rale, in Latin rhonchus.* There is considerable variety in these sounds ; but several of them are sufficiently well characterised to be entitled to distinct appellations; and these are most valuable diagnostic signs. The different kinds of rhonchi have their site either in the air-cells, or bronchial tubes, or in some morbid excavations formed in the substance of the lungs ; and they are caused either by some substance within these, more or less fluid, and moving in contact with air, or by some other ob- struction in the air-passages from external com- pression or alteration of their coats. A considera- tion of these different causes, and of the sounds resulting from them, seems to point out a very convenient mode of arranging them as follows :— 1. Rhonchi having their site in the vesicles or air-cells — vesicular rhonchi,- 2. rhonchi having their site in the bronchial tubes—bronchial rhon- chi ; 3. rhonchi having their site in morbid exca- vations—cavernous rhonchi. All the causes of these sounds may be divided into two kinds, ac- cording as they are dependent on the presence of a liquid, or on some change in the coats or caliber of the air-passages, or on obstruction from matter of a solid kind. The different kinds of rhonchi may therefore be termed either humid or dry. We shall thus have our classification as follows :— I.— Vesicular rhonchi. 1. Humid vesicular rhonchus—Moist crepitous rhonchus—Rale crepitant of Laennec. 2. Dry vesicular rhonchus—Dry crepitous rhon- chus—Rale crepitant sec a grosses bulks, ou craquement of Laennec. II.—Bronchial rhonchi. 1. Humid bronchial rhonchus—Mucous rhon- chus—Rale muqueux of Laennec. 2. Dry bronchial rhonchus. a. Sibilous rhon- chus—Rale sibilant sec of Laennec. b. Sonorous rhonchus—Rale sonore sec of Laennec. III.—Cavernous rhonchi. 1. Humid cavernous rhonchus — Cavernous rhonchus — Gargouillement, Rale caver- neux of Laennec. 2. Dry cavernous rhonchus. This species is added more on account of uniformity, and because it is possible, than because such a variety has been described. 1. Moist crepitous rhonchus, or humid vesicu- lar rhonchus.—The sound characteristic of this variety is compared by Laennec to the crepitation of common salt when thrown on hot iron ; by Dr. Williams to the sound produced in rubbing between the finger and thumb a lock of hair, close to the ear. Other comparisons have been adduced, such as the noise of boiling butter, that occasioned * It is very desirable that some name might be found for this phenomenon which would prove generally accept- able to British physicians. In the translation of Laen- nec the nearest English synonyme, rattle, was used, hut this word has been adopted by few. The original French term rale appears to be most generally employed in this country ; but there are several objections to its use. In the present article we shall give a general preference to the Latin synonyme, rhonchus, also employed by Laennec. 250 AUSCULTATION. by the bursting of the minute bubbles on the sur- face of beer or soda-water, &c. Of these the comparison of Dr. Williams comes nearest the natural sound; but that which resembles it still more closely is the crepitation of a healthy lung distended with air, when compressed in the hand. Perhaps as just a notion of it may be conveyed to the mind by imagining the quality of roughness superadded to the pure or smooth sound of healthy respiration. But, of course, a perfect knowledge of the sound in question can only be obtained by the actual perception of it, and the student is re- commended to lose no opportunity of making himself acquainted with it, as it constitutes a sign of great practical importance. The cause of this sound is, no doubt, to be sought for in the com- mixture of the respired air with the secreted fluids; and whoever considers the intimate churning of the two fluids in a confined space like the air- cells, need have no difficulty in admitting this as the true explanation of the phenomenon. It is very probable that the mere increase of the natu- ral humidity of the membrane, without any formal accumulation of fluid, or even that some other physical alteration of this, without increased secre- tion, may occasionally give rise to the crepitous rhonchus : although, as it occurs only in cases in which we know an augmented secretion to be present, there is every reason to admit the pre- sence of fluid as one of the elements in its pro- duction. The moist crepitous rhonchus is one of the most constant and characteristic signs of the first stage of peripneumony, appearing with its invasion, disappearing on the "supervention of hepatization, and re-appearing with the partial resolution of the inflammation. At its commencement this rhon- chus alters and obscures the natural respiratory sound, but does not entirely mask it.- as the in- flammation increases, so does the intensity of the morbid sound, until this at length entirely super- sedes the other. This rhonchus, however, is not exclusively confined to pneumonia ; being ob- served in oedema and apoplexy of the lungs, and occasionally in pulmonary catarrh and bron- chitis ; and, according to Dr. Stokes, in the early- stage of phthisis, during the formation and deve- lopment of tubercles. (Irish Transactions, vol. v. p. 326.) Indeed, if we admit that the presence of fluid, the effect of inflammation, in the air-cells, suffices for its production, we must expect that it should be occasionally present in the other dis- eases mentioned. But its occurrence in them is certainly very rare, while it is so constant a con- comitant of the first stage of pneumonia as to justify its being considered as almost pathogno- monic of it. In different states of the diseases above mentioned, we meet with intermediate varieties between the moist crepitous and the mucous rhonchus hereafter to be described.— These varieties can scarcely be characterised by words. In the case of oedema, and also in pul- monary apoplexy, the crepitous rhonchus, ac- cording to Laennec, conveys the impression as if it originated in the rupture of larger bubbles than in the case of pneumonia, in which the bubbles appear to be of extreme minuteness. In a late work on Auscultation, by Mr. Spittal, some account is given of the sounds produced by the bursting of bubbles on the surface of different fluids when agitated. He found that fluids of the density and tenacity of serum gave rise to sounds most nearly resembling those of the moist crepitous rhonchus; and M. Piorry states that the very same sound is produced in the dead body by injecting fluids into the lungs. (Du Procede Operatoire, pp. 81, 94. 2. Dry crepitous rhonchus, or dry vesicular rhonchus.—This variety occurs only in emphy- sema of the lungs. Laennec says it exactly re- sembles the sound produced by blowing into a dried bladder, and conveys the impression of the inspired air entering and distending lungs which had been dried, and of which the cells were un- equally dilated; but it is somewhat to be sus- pected that his knowledge of the physical change in the affected parts may have helped to suggest this similitude. It is certainly a very different sound from that last described; and it is a pecu- liar sound. It is observed most distinctly in the interlobular emphysema. In any case it is only heard during inspiration. 3. The mucous rhonchus, or moist bronchial rhonchus. This, as its name implies, has its site in the bronchial tubes, and not in their terminal extremities or air-cells. It is evidently produced by the passage of the air through tubes contain- ing a fluid, and is, in fact, a mere bubbling going on within the bronchi. Laennec says that it presents many varieties which can be best con- ceived by comparing the perceptions derived from the sense of hearing, with such as we fancy might be conveyed by the sense of sight In listening to it, our mental impressions are similar to those conveyed by what we see and hear when one blows through a pipe into soapy water. The ear seems to appreciate most distinctly the consist- ence of the fluid which forms the bubbles, and also their varying size. The consistence of the fluid always appears, and probably is, greater in the bronchial than in the vesicular rhonchus. The moist bronchial rhonchus belongs principally to the pulmonary catarrh and bronchitis, when accompanied with much mucous secretion, and to haemoptysis. It is obvious, however, that it may occur in every disease of the lungs attended by considerable expectoration, as in pneumonia and phthisis. A mere variety of this rhonchus is that named tracheal by Laennec, the fluid oc- casioning the sounds being in this case accumu- lated chiefly in the trachea. In this variety, as the caliber of the tube is larger, and the elements of sound (if the expression may be allowed,) in greater quantity, the sound is proportionally in- creased—resembling occasionally, according to the expression of Laennec, the rolling of a drum at a distance, or the noise of a carriage on a paved street In such cases the sound is com- monly perceptible without the aid of the stetho- scope; but sometimes when found to be very loud with this instrument, it is not heard by the bystanders. The tracheal rhonchus frequently masks the sounds of the heart and the other rhonchi when present: it may exist singly, but it is usually complicated with the common bron- chial rhonchus. The bronchial rhonchus is va- luable both as a diagnostic and prognostic sign. It is often the best test we possess of the severity AUSCULTATION. 251 of bronchitis, by indicating the extent of the affection; the danger of this disease being fre- quently marked by the extent of membrane in- flamed. 4. The dry bronchial rhonchus.—This includes two varieties, the sibilant and sonorous rhonchus. The former is described by Laennec as being sometimes like a prolonged whistle, shrill or base, low or loud; sometimes like the momentary and interrupted chirping of birds, or the sound emitted by the sudden separation of two portions of smooth oiled stone. The sonorous rhonchus is a dull, flat, prolonged sound; sometimes ex- tremely loud. At one time it resembles the snoring of a person asleep, at another the bass note of a violoncello or bassoon; and, occasion- ally, it is so like the cooing of a pigeon that we might almost be tempted, as Laennec says, to fancy the bird below the patient's bed. These varieties of sound, and many others, frequently coexist in the same person. They are, in all probability, occasioned by the causes to which they were originally attributed by Laennec, viz. a diminution in the caliber of some portion of a bronchial tube, by external pressure, (as of an enlarged gland or hepatized spot,) by the pre- sence of a tenacious clot of mucus within the canal, or by the local thickening of its mem- brane. Adopting Laennec's views, Dr. Williams explains the different resulting sounds in the following manner. He says, the form and size of the isthmus, or contracted point, will deter- mine the nature of the sound. Of the acute whistling sound, called the sibilant rhonchus, he observes that, as we know that such a sound may be produced by air passing through a small circular aperture, it may be supposed that a con- traction of this kind causes it in this case. « The sonorous rhonchus is rather produced by a flat- tened bronchus of considerable size. This con- traction, which leaves little or no gaping aper- ture, throws the air passing through it into sonorous vibrations, after the manner of the reed of the hautboy, or the lips Lfi blowing a horn; or, perhaps, the production of this sound is still more completely represented in the manner in which a celebrated ventriloquist imitates, with his lips, the buzzing of a fly." In another va- riety of the sonorous rhonchus, noticed by Laen- nec, and which Dr. Williams well characterises as resembling " the sound of a click-wheel," the sound is probably produced, as Dr. Williams says, " by a portion of very viscid mucus at- tached to the interior of a bronchial tube, which, yielding with a jerking resistance to the air forcing its passage, thereby causes a ticking sound."—(Rational Exposition, &c. p. 32.) 5. The cavernous rhonchus. — The rhonchi hitherto mentioned, although depending on a morbid condition of the part in which they ori- ginate, still have their site in cavities naturally existing in the state of health; that now to be considered is in every respect morbid—in its site as well as its cause. It may exist in all cases where there is a morbid excavation in the lungs containing a fluid, and communicating with the bronchi; as in circumscribed abscess, and in local gingrene of the lungs, and in the latter stages of tubercle. The last named is by far the most usual source of this sign, insomuch that we doubt if it arises once in a hundred times from any other cause. It is characterised by a strongly marked mucous rhonchus or guggling, confined to a small spot, instead of being diffused over a considerable portion of the lung, as is usually the case with the common humid bronchial rhon- chus. It is particularly heard upon the patient taking a deep inspiration, or after coughing; and if, under such circumstances, it is very strongly marked, continues fixed in the same point, and is not heard in any other, it is one of the surest signs of tuberculous excavation, even without pectoriloquy and the cavernous respiration, which will generally be perceptible in the same point. Andral, a high authority, considers this circum- scribed bubbling rhonchus, when well marked, as the very surest sign of a tuberculous cavity. In reference to all these louder rhonchi, it is well to recollect that they are often audible through a pleuritic effusion: we must not there- fore conclude from their mere presence that the lungs are in contact with the chest B. The second class of morbid sounds which complicate healthy respiration comprehends fewer varieties, and these of less importance than the last 1. Metallic tinkling, or metallic resonance.— This name, literally translated from the original epithet bestowed on the sound by Laennec, (tin- tement metallique,) applies to one of the most singular, though not one of the most important results obtained in the exploration of thoracic diseases by means of auscultation. This sound is observed only in cases where there exists within the chest a large preternatural cavity con- taining air. By far the most common occasion of it is the presence of air in the sac of the pleura in the disease termed pneumothorax. It however is observed, although very rarely, in other cases, particularly in very large tuberculous excavations. As in the great majority of cases of pneumothorax there coexists with the gas a liquid effusion in the pleura, and likewise a com- munication between the pleural cavity and the bronchi, Laennec, the discoverer of the pheno- menon, was led to consider its production as almost exclusively confined to this complex mor- bid state. It has, however, been since proved that neither the existence of liquid effusion, nor the communication with the bronchi, is necessary to its production. The sound is most commonly excited by the act of respiration, or speaking, or coughing; but it also arises independently of any of these. Coughing produces it more frequently and more certainly than any of the other respi- ratory acts. There are two varieties of this phenomenon, the one known by the general name of metallic tinkling; the other termed by Laennec amphoric resonance, or buzzing, (bour- donnement amphorique.) The first of these varieties resembles the sound emitted by a cup of metal or glass when gently struck with a pin, or into which a very minute pebble or grain of sand is thrown; or it is like the sound of a brass wire vibrating under a sharp but gentle stroke of the finger. The amphoric resonance is of a character less definite, but not less distinct It is like the sound produced by 252 AUSCULTATION. blowing quickly and forcibly into a bottle or other large empty vessel having a small aperture. It is also called metallic resonance. Both these sounds are most frequently occa- sioned by the impulse communicated to the gaseous fluid in the sac of the pleura, by a blast of air from a fistulous opening in the lungs; the difference of sound depending, most probably, on the nature of the opening. They also origi- nate when there exists no such opening, the im- pulse being conveyed from the air within the bronchi through a stratum of condensed pulmo- nary substance, or other matter capable of com- municating it, to the air in the cavity, the vibra- tions of which are the immediate cause of the peculiar sounds. The first of the two sounds, the metallic tinkling, is likewise found to arise without any external impulse, by the mere falling of a drop o/ fluid from the superior part of the cavity into the fluid collected in the under part of it. The value of these sounds as signs of disease will be noticed in the article Pneumo- thorax, to which the reader is referred. 2. Sou7id of friction. This sound, termed by Laennec bruit de frottement ascendant et de- scendant, is rather connected with the thoracic movements which effect respiration than with respiration itself. It was first observed by Dr. Honore, but has been since more completely in- vestigated by M. Reynaud, one of Laennec's pupils. It is an obscure dull sound, quite dis- tinct from the respiratory murmur, but exactly synchronous with the motions of inspiration and expiration. This sound is precisely such as we might conceive would be produced by the friction of a body, somewhat rough, against the inner side of the walls of the chest, rising and descend- ing regularly with the respiratory movements. It is in general proportioned to the extent of these, being loudest during deep inspirations, and in some cases only audible then. This sound is found to occur only when there exists consider- able roughness or inequality on the surface of the lungs or costal pleura. Laennec considered this sound as a sign of interlobular emphysema; and it seems probable that it is so in certain cases. It has, however, been found more certainly in pleurisy, when the membrane was rendered rough by partial effusions of a solid albuminous kind, with little or no accompanying serum. In this case it is well established as a sign; and it may be regarded as of favourable omen, inasmuch as it denotes a moderate effusion, and that the lung is sufficiently dilated to come in contact with the walls of the chest.* Auscultation of the Voice. — If we apply the hand to the chest while a healthy person is speaking, we are almost always sensible of a slight vibration, at least, evidently produced by the sound of the voice; and a vibratory sensa- tion, rather than a formal sound, is communi- cated, under similar circumstances, by the stetho- scope, to the ear. [Great discrepancy exists amongst observers, in regard to the true signification of this vocal *De I'Auscult. Med. 3me. edit. t. i. p. 120. Ibid. p. 335, mote. Ibid. torn. ii. p. 319, note.—Reynaud, Journ. Heb- dom. No 65, p. 576.—Andral, Clin. M£d. 2me. edit, t. ii. p. 613. fremitus and its modifications, as the following table, by Dr. Walshe, clearly exhibits. (The Physical Diagnoses of Diseases of the Lungs, Amer. edit p. 164, Philad. 1843.) NATURAL VOCAL FHKMITT7S. Increased. DimiDiibed. I Unaffected. Laennec. Stokes. In consolida-tion and in effusion. Rbynaod. Williams. HotlRMANN. In consolida-tion. In effusion. Grisolle. In consolida-tion, from pneumonia at least. Fournet. Impossible in any case. In all changes of density, whether of increase or decrease. Dr. Walshe is, we think, correct in entertain- ing not the slightest doubt, that M. Fournet is in error in the principle which he affirms in regard to the non-increase of vibration. Like Dr. Walshe, we have found it manifestly augmented in cases of tuberculous consolidation of the top of the lung, as well as in pure hepatization. Dr. Walshe adds, that he cannot help feeling, that there is something of importance yet to be dis- covered respecting this sign, which may furnish a ready clue to the contradictions in the state- ments of writers on the subject.] In many cases, indeed, particularly in persons who have large chests and a base voice, we recog- nise a distinct vocal resonance over the whole chest. And in every case, when we apply the stethoscope over the origin of the larger bronchial tubes, as between the scapuhe, we hear the voice much more distinctly; sometimes even as loud as the voice from the speaker's mouth. The words are also sometimes distinguishable; but they appear as if playing round the extremity of the instrument, and not as entering, much less traversing, its tube. When, however, we place the stethoscope on the larynx or trachea, on the fore-part of the throat, while the individual is speaking, we then hear the whole of the words passing directly through the instrument into the ear, exactly as if the mouth, in place of the larynx, were applied to the end of the instru- ment; and the voice so heard is much louder than the natural voice heard by the other ear. The cause of these sounds (denominated by Laennec, from their site, bronchophony and laryn- gophony) depends, no doubt, on the fact, that, in the act of speaking, the vocal vibrations always extend inwards along the air-tubes, as well as outwards through the mouth and beyond it. The stethoscope merely supplies a conductor for their conveyance to the ear. The vocal sounds are loud and distinct in the trachea, because there is sufficient space there for the aerial vibrations that constitute the sound; because the more solid walls of this part are well calculated to propa- gate it; and because it lies near the surface. The gradual loss of all these conditions favourable for the generation and propagation of sound, as the trachea descends into the chest and there becomes AUSCUL transformed into small tubes traversing the spongy texture of the lungs, sufficiently explains the im- perfection of the vocal resonance in the larger bronchi, and its total absence in the smaller branches. In certain states of disease, however, both the bronchial and laryngeal sounds become deve- loped in places where they do not naturally exist; and as it has been ascertained that the causes of this morbid development of the voice are certain fixed physical changes of structure, these voices from the chest become important signs of disease. [In the space, corresponding posteriorly to the origin of the right bronchium, the voice resounds more strongly than in the corresponding part of the left side. According to Sir James Clark, the natural resonance is more intense under the right than the left clavicle, and with this our ob- servation accords. Dr. Stokes, indeed, considers that it is more intense over the whole of the right side. (On the Diseases of the Chest, p. 297, Dubl. 1837.)] The sounds produced within the chest by the voice, that are available as signs of disease, arc of three kinds, and may be arranged as follows: —1. Simple bronchophony, or bronchophony with the healthy character, only developed in places where it does not exist in health; this, for the sake of brevity, we shall term bronchophony. 2. Complex bronchophony, or bronchophony with the healthy sound modified in a peculiar manner, and developed in places where it does not exist in health: this is termed xgophony. 3. Perfect laryngophony developed in the chest: this is termed pectoriloquy. I. Bronchophony. The same causes which render bronchial respiration audible in disease, in places where it is not perceptible in the state of health, render bronchophony equally audible, and for the same reason, viz. by rendering the pul- monary tissue a better conductor of sound. Whenever, therefore, we have the substance of the lungs considerably condensed in the vicinity of bronchial tubes of moderate size, without obliteration or great compression of their caliber, we may expect to have bronchophony developed. The morbid states in which it is found are chiefly hepatization and induration from the deposition of solid tubercular matter. It may also originate in other kinds of condensation of the pulmonary tissue, such as pulmonary apoplexy, melanosis, &c, and also in certain cases of dilatation of the bronchi. [This last fact shows, that consolidation is not necessary to induce increased resonance of the voice. Dr. Skoda, indeed, maintains that bron- chophony is not always a persistent phenomenon in hepatization; that at one time it is very strong; at another equally weak; and the cause of the occasional disappearance of resonance he con- ceives to be—the obstruction of the tubes of the hepatized part by fluid matters; as the resonance readily reappears when the patient makes a deep respiration or coughs. Dr. Skoda refers bronchophony to consonance or reciprocation — a well-known acoustic phenomenon; and the fact, above-mentioned, of the occasional dis- appearance of the resonance when the lung is unquestionably hepatized, seems to corroborate w ATION. 253 this view. (For the auscultatory views of Skoda, see Edinb. Med. and Surg. Journal, for July 1841; or American Med. Intelligencer, for Aug. 1841.)] The general characters of this morbid, or acci- dental bronchophony, as it is termed by Laennec, are as above described; some further particulars of the sound will be noticed in the subsequent paragraphs, when we come to contrast some other sounds with this. Bronchophony is most valuable as a sign in peripneumony and in phthi- sis. In the former it is most evident when the inflammation exists near the roots of the lungs, and in the upper lobes where the bronchi are largest: it is much less frequent and more ob- scure in the lower lobes. When the hepatization has its site very near the surface of the lungs, and where the bronchi are particularly large, it frequently approximates to laryngophony. The bronchial respiration is always present with bron- chophony ; and frequently also the common vesi- cular respiration, except in cases where the hepa- tization is very extensive. Bronchophony is a less important sign in phthisis, but when existing, as it frequently does, beneath the clavicles, par- ticularly if on one side only, and other symptoms of this disease are present, it tends strongly to confirm the general diagnostic. II. Mgophony.— If in any of the cases in which the preceding sign exists, a thin layer of fluid is superadded, between the surface of the lungs and costal pleura, the natural simple sound of broncophony is so much and so peculiarly altered as to merit and obtain a distinct appella- tion, and be considered as a distinct sign. This modification of bronchophony has been termed aegophony by Laennec, (from a\\, aiybc, capra), because it possesses somewhat of the broken, bleating cry of the goat, and approaches the usual key of this animal's voice. It is a kind of sil- very voice, of a sharper and shriller tone than that of the patient, seeming to float and vibrate on the surface of the lungs, and sounding more like the echo of the patient's voice than the voice itself. Different varieties of this phenomenon resemble more or less closely various sounds with which all are more or less familiar, e. g. the voice through a speaking-trumpet, or cleft reed; that of a person speaking with something between his lips and teeth; the squeaking of Punch, &c. The last-mentioned comparison is certainly some- times extremely exact, particularly in persons who have a base voice. The sort of bleating so characteristic of segophony, seems, in most cases, connected with the articulation of the words; sometimes it seems unconnected with this, so that we can hear at the same time, yet separately, the simple sound of the natural voice, and the bleat- ing sound of asgophony. In order to hear the sound well, the instrument must be applied with considerable force to the patient's chest, but the ear must not be pressed against the other end with more than the usual force. ^Egophony only exists in pleurisy or hydrothorax, when the quan- tity of effused fluid is just sufficient to form a thin layer between the surface of the lung and costal pleura. The compression produced by the external fluid seems to produce the requisite de- gree of condensation of the pulmonary substance, to enable it to conduct the bronchial resonance, 254 AUSCULTATION. and the passage of this through the stratum of mobile fluid on the surface, seems to occasion the peculiar modification of the sound above described. Dr. Williams says, that in addition to the pre- ceding requisites, there must likewise exist a cer- tain proportion between the mass of liquid and the pitch and strength of the vocal sounds, other- wise the fluid will not be thrown into vibration. This, he says, is proved by the fact that certain tones of the same voice are segophonic and others not. (Rational Exposition, p. 107.) JSgophony is always found to extend over a certain portion of one side of the chest, being most commonly perceptible, at the same time, in the intrascapular region, round the lower angle of the scapula, and in a zone, from one to three fingers broad, follow- ing the line of the ribs, from the middle of this bone to the nipple. Of its importance as a sign in pleurisy, we need only quote the statement of Laennec, who says that he had observed it in almost every case of pleurisy which had come under his care for the last five years before the publication of his second edition. The same au- thor adds, that he has detected aegophony where there did not exist above three or four ounces of fluid within the chest JDgophony only exists, as already said, when the effused fluid is in mo- derate quantity; it therefore is found to disappear when the pleuritic effusion surpasses this amount, and it again returns when absorption has reduced it to the proper quantity. The original opinion of Laennec as to the cause of this singular phe- nomenon, seems to be generally admitted as just. He says, " I consider sagophony to be owing to the natural resonance of the voice in the bron- chial tubes, rendered more distinct by the com- pression of the pulmonary texture, and modified by its transmission through a thin layer of fluid in a state of vibration." Dr. Williams says, that " the tremulous or subsultory sound of the sego- phonic voice is produced by the successive undu- lations of the liquid, the result of an irregular transmission of the sonorous vibrations." ^Ego- phony and bronchophony frequently exist toge- ther, as might be naturally expected; and, although each is sufficiently well marked to be recognised by its distinctive characters, like all similar phe- nomena they run into each other, and it is not seldom impossible to pronounce with certainty whether the sound is the one or the other. III. Pectoriloquy. The most singular, as it was one of the first, of the results of Laennec's exploration of the voice, was the discovery of per- fect laryngophony in different parts of the chest as the consequence of disease. The condition of parts necessary to produce this curious phenome- non (termed by the discoverer pectoriloquy, or chest-speaking, from pectus and loquor,) is the existence of a preternatural cavity communicating with the bronchi, amid the spongy texture of the lungs; the existence, in short, of a sort of artificial larynx, or space sufficient for the full development of the vocal vibrations, which always exist, in a modified degree, in the larger air-tubes. When the stethoscope is placed on the chest directly over a cavity of this kind, the articulate and perfect voice of the individual seems to reach the ear through the tube, as distinctly as when this is placed on the larynx ; and the voice thus heard is often louder and more distinct than the natural voice that issues from the mouth. Cavities of this kind are occasionally produced by more than one disease of the lungs ; but in a vast majority of cases they are the result of the suppuration or softening of tubercles. The other cases in which this phenomenon may be perceived are, according to Laennec, the following : cavities produced by the dissolution of a gangrenous eschar, by an abscess the consequence of peripneumony, and by the bursting of a cyst into the bronchi. When pectoriloquy is well marked, there is a perfect identity between it and the sound of the voice heard through the stethoscope when resting on the larynx : and as this means of comparison is always at hand, a reference to it will be more serviceable than any description of the sound however elabo- rate. It is to this that the student must always recur as a test of the fidelity of his judgments in exploring the chest for pectoriloquy. It is, how- ever, well that he should be made early aware that pectoriloquy so perfect as this is by no means of universal occurrence in phthisis, even in cases in which we have other proof of the existence of tuberculous cavities. Indeed, we are disposed to believe with Andral that perfect pectoriloquy is by no means extremely common, and that broncho- phony is frequently mistaken for it. Laennec was well aware that pectoriloquy was often very different in different cases, according to the size, shape, and nature of the walls of the cavity, its degree of emptiness or fulness, its mode of com- municating with the bronchi, its particular site in the lungs, &c. &c.; and he was careful in de- scribing several varieties of it The principal of these he termed perfect imperfect, and doubtful pectoriloquy. He considers it perfect only when the transmission of the voice through the instru- ment is complete, and when it can be still further discriminated from bronchophony, by being con- fined to one spot, and by the corresponding cir- cumscription of the cavernous respiration and cavernous rhonchus, which commonly accompany it It is imperfect when any one of these character- istics is wanting, and especially if the transmission of the voice is not evident. It is doubtful when the sound of the voice is very feeble, and when it can be distinguished from bronchophony only by the aid of other signs derived from the considera- tion of its site, the general symptoms, and the progress of the disease. The circumstances which concur to render pec- toriloquy perfect are, the complete emptiness of the cavity, the increased density of the pulmonary substance which constitutes its walls, its free communication with one or more bronchial tubes of a certain diameter, and its proximity to the walls of the chest. The absence of more or fewer of these conditions will tend to render pectorilo- quy more or less imperfect; but it may be very imperfect and yet not at all doubtful as a sign of the existence of a cavity. In all cases of imperfect pectoriloquy, the discovery of the same sound on both sides must always render it doubtful. It is however to be recollected that the most perfect pectoriloquy may become in an instant very im- perfect, or may entirely disappear, owing to the changes that may take place in the contents of the excavation, or of the bronchi leading to it Ex- AUSCUL cavations of a moderate size, and of a regular rounded shape, give the most perfect pectoriloquy. If the caverns are very large or irregularly shaped, the sound of the voice is indistinct, and this is also the case if they are very small. The more empty the cavities are, the pectoriloquy is the more evident It is also more distinct according as the voice of the individual is more sharp; and as women and children have this kind of voice most commonly, it is well remarked by Laennec that we must be particularly on our guard, in their case, not to confound natural bronchophony with pectoriloquy. The deeper the voice is, the reso- nance within the chest is the stronger; and it often happens, in such cases, that in place of pene- trating the tube of the instrument, it seems to sound at its extremity much louder than the natu- ral voice ; as if the patient were speaking through a speaking-trumpet quite close to us, and not through the stethoscope into the ear, as in com- mon pectoriloquy. For further details respecting this sign, we must refer to the article Phthisis, in which disease it constitutes a most important Bign. We must, however, be permitted to observe that too much stress has been laid upon the value of pectoriloquy as a pathognomonic sign of phthi- sis. Where it clearly and unequivocally exists, it is unquestionably pathognomonic ; and in many doubtful cases it is of inestimable value in deter- mining the nature of the disease. It cannot, how- ever, be denied that it is only in rare cases that its discovery influences either our diagnosis, prognosis, or practice. The rational signs of phthisis serve, in the great majority of cases, sufficiently to cha- racterise it; and when these are corroborated and crowned by the addition of pectoriloquy, the case is in almost every instance already beyond the power of remedy. And yet we are far from wish- ing to represent this sign as of little value even in phthisis. It is by it alone, or by it and the other phy- sical signs produced in caverns by the respiration and cough, that we can be certain of the existence of tuberculous cavities at all, or of their situation, number, or extent; and every pathologist knows how much the prognosis at least, if not the treat- ment, may be improved by this knowledge. Be- sides, there are several cases, of not very rare occurrence, in which such knowledge is of infinite value both as to prognosis and treatment. One of these is when all the rational symptoms of phthisis are produced by chronic bronchitis ; and another where one or two tuberculous excavations exist in an otherwise sound lung, and without producing any of the rational or constitutional symptoms of phthisis. It is unnecessary to say of what value to the practitioner will be the assu- rance of the non-existence of pectoriloquy in the one of these cases and its existence in the other. In the latter case, the voice from the chest may announce the speedy approach of suffering, and sorrow, and death, perhaps amid all the outward semblances of health; and in the former, its silence to all our questioning may not merely bid hope take the place of despair in the breast of friends, but may awaken the physician from the torpor of inactivity, and induce him to adopt such measures as may convert this hope into certainty. [It has been proposed to associate auscultation with, percussion;—in other words, to listen with ATION. 255 the common stethoscope, or with one modified for the purpose, whilst a part is struck in the ordinary method of mediate percussion ; and value has been assigned to auscultatory percussion, acouophonia, or cophonia, thus practised ; but it has not been much used, and is affirmed by M. Fournet (Re- cherches Cliniques sur I'Auscultation, &c. Paris, 1839,) to be deceptive,— the perceived sound bearing no precise relation to the condensation or rarefaction of the adjacent parts. Hence, it has been denounced, but in too strong language, per- haps, by Dr. Walshe, as " obviously worse than useless." (The Physical Diagnosis of Diseases of the Lungs,- Amer. edit p. 154 : Philad. 1843.) The term autophonia has been given, by M. Hourmann, to an auscultatory process, of which M. Taupin considers himself the inventor. It consists in noting the character of the observer's own voice, whilst he speaks with his head placed close to the patient's chest. The voice, it is alleged, will be modified by the condition of the subjacent organs. M. Hourmann considers it a really useful sign in the examination of infantile diseases. (Walshe, Op. cit.)] Auscultation of the Heart. If we apply the ear, with or without the stetho- scope, to the cardiac region of a person in health, we perceive, most distinctly, a series of sounds of a very marked and peculiar kind, subdivided into uniform parts by a brief interval of silence, after every second sound. Two sounds follow each other instantly, or within so short a space that the ear separates them rather by difference in their quality than from the intervention of any notable cessation of sound : then ensues a brief but well- marked pause, which is again succeeded by the first of the twin sounds. This series of sounds may be perfectly well represented, as to rhythm, by musical notation. The relative duration of the sounds and pause is represented by Laennec to be nearly as follows : the whole being divided into four parts, two of these are occupied by the first sound, and one by the second sound and the pause respectively. The two sounds differ in kind as well as in duration. The first is nearly double the length of the second, of a graver and more subdued tone, rather louder at its commence- ment than at its termination, as if it was about to die away when suddenly interrupted by the second. The second is brief, smart, and clear, like a gentle tap with the pulp of the finger on a solid table, or, according to Laennec's comparisons, like the sharp sound produced by the falling back of a valve, the cracking of a whip, or the lapping of a dog. [To convey a notion of these sounds, Dr. C. J. B. Williams employs the compound word lubb-dup, the first word of the compound expressing the protracted first sound ; the latter the short second sound.] Exactly synchronous with the first sound, there is perceptible, in most cases, a well- marked impulse or shock, communicated evidently by a body in motion within, to the walls of the chest. Every one acquainted with anatomy and physiology will at once conclude that the sounds and impulse just described are produced by the motions of the heart; and this conclusion will be justified and confirmed by an examination of the pulse in the extremities. It will be found, in all healthy subjects, that there is an invariable con- 256 AUSCULTATION. nexion between the sounds and the pulse, every stroke of the latter corresponding very accurately with every repetition of the twin sounds. As, under every variation of circumstances as to loud- ness, frequency, &c, the same exact relation is perceived, it cannot be doubted that there exists an essential physical connexion between the causes of the sounds and the pulse. For a long time after the discovery of mediate auscultation, no doubt was entertained that the exposition of the motions and sounds of the heart, given by Laennec, was the true one. He asserted that the first of the two sounds accompanied and was caused by the contraction of the ventricles ; the second by the contraction of the auricles; and that the pause intervened between the auricular and the ventricular sounds. As a necessary con- sequence of this doctrine, he taught that in the natural rhythm of the heart, the ventricular sys- tole comes first; is followed immediately by the auricular systole; and this, in its turn, by the interval of repose. The accuracy of these statements of Laennec was first called in question by Mr. Turner, in a paper published in the third vol. of the Edin. Med. and Chir. Transactions ; and the subject has been since more completely illustrated by the observa- tions and experiments of Drs. Corrigan, Stokes, and Hope.* The experiments of the last-named physician made on large animals (asses) are par- ticularly deserving our attention and confidence. They are of such a kind, indeed, as, in our opin- ion, to set the question at rest; the results having been repeatedly witnessed by many most compe- tent judges, and being in complete accordance with the pathological phenomena observed in the human subject, during life and in the dead body. Dr. Hope has recently repeated his experiments, with results precisely similar to those formerly obtained, and has been kind enough to favour us with a sketch of the natural movements of the heart and the relation of the sounds to them. This we shall here give almost in Dr. Hope's own words, being happy to avail ourselves of an au- thority so deservedly high, founded as it is on the most extensive observation particularly devoted to the subject. Rhythm of the heart—The first motion of the heart which interrupts the interval of repose, is the auricular systole. It is a very slight and brief contractile movement, more considerable in the auricular appendix than elsewhere, and propa- gated with a rapid vermicular motion towards the ventricle, in the systole of which it terminates rather by continuity of action than by the succes- sion of a new movement. The ventricular systole commences suddenly, and is accompanied with a considerable diminution of the volume of the organ. Synchronous with the systole are the first sound, the impulse of the apex against the ribs, and the pulse in vessels near the heart: in the radials the pulse follows at a barely appreciable interval. The systole of the ventricles is followed by their diastole, during which they return, by an instantaneous expansive movement sensible to the touch and sight, to the same state (with respect to size, shape, position, &c.) as during the pre- * See the communications of these gentlemen in the Lancet, Edinb. Journal and Med. Gazette. vious interval of repose. This movement, or dia- stole, is accompanied by the second sound, by an influx of blood from the auricle, by a retractile motion of this cavity most observable at its sinus, and by a retrocession of the apex of the heart from the walls of the chest. Next succeeds the interval of repose, during which the ventricles remain at rest, in a state of fulness, though not of distension, through the whole period intervening between the second and the first sounds; but the auricle remains at rest during the first portion only of that period, the remainder being occupied by its next contraction, with which recommences the series of actions described. The duration of the several parts of a beat is the same as described by Laennec ; namely, 1. The ventricular systole occupies half the time, or thereabouts, of a whole beat. 2. The ventricular diastole occupies one-fourth, or at most one-third. 3. The interval of ventricular repose occupies one-fourth, or rather less, during the latter half of which the auricular systole takes place. Causes of the motions.—The auricles, which are always in a state of fulness, arrive, during the first half of the period of ventricular repose, at the state of distension, by which they are stimulated to contract. The object of the contraction at this moment is to propel a small additional quantity of blood into the ventricles, for the purpose of bringing them from the state of fulness to that of distension; an object which could not be accom- plished without a contraction, as the blood could not otherwise force its way into the ventricles against the resistance offered by their elasticity. These cavities, then, being brought to the state of distension, are by this stimulated to contract: they expel a greater or less proportion of their contents : in small animals, frogs for instance, they expel the whole; which is proved by the ventricle becoming pale. In large animals they do not appear to expel the whole, but the fact does not admit of demonstration. During the act of expulsion, the apex is tilted up, in consequence of the retraction of the ventricles towards the base and upon the auricles, which, in a state of ex treme distension, are placed like a fulcrum beneatn them. The diastole appears to be occasioned by several concurrent causes, viz. 1. That power of the muscle by which it reverts from the state of contraction to that of relaxation, and in virtue of which it exercises a degree of motion. It may be called elasticity until its nature is more positively determined. 2. The distension of the auricles, which is greater at this moment than at any other, as they have been tilling during a longer period ; namely, that of the ventricular contraction, or half a whole beat 3. The weight of the ven- tricles collapsing on the distended auricles under- neath them. 4. The width of the auriculo-ven- tricular orifice, which allows the blood to shoot in instantaneously and with great facility. It is obvious that, as so many powerful causes conspire to promote the influx of the blood, an auricular contraction for this purpose, as imagined by Laen- nec, would be superfluous. The escape of blood from the auricles during the diastole, causes the slight retraction observable in them at the same moment. The expelled blood being instantly re- AUSCULTATION. 257 placed from the vena? cavse, distension of the auricles recommences, and the same series of actions is renewed. Causes of the sounds.—The ventricular systole is the cause of the first sound, by the impulse which it communicates to the blood within it, thereby exciting sonorous vibrations of that fluid. If the sound of the muscular contraction contri- butes at all to the first sound, it can be only in a very slight degree. The ventricular diastole is the cause of the second sound, by the re-action of the walls on the blood, and the consequent production of sonorous vibrations, when its course is abruptly arrested by the completion of the dias- tole. Hence this sound is loud, brief, and clear. The auricles are not concerned in the production of the two sounds, as they take place when these cavities are motionless ; nor do they appear to be productive of any sound, as no third sound is audible. [The causes of the two sounds can scarcely be regarded as settled. From accurate experiments made by Drs. Pennock and Moore, of Philadel- phia, (Medical Examiner, Nov. 2, 1839 ; and American Medical Intelligencer, Dec. 16, 1839 ; or Pennock's edition of Hope On Diseases of the Heart, Philad. 1842,) they suggest, that the first sound may be a combination of that caused by the contraction of the auricles, the flapping of the auriculo-ventricular valves, the rush of blood from the ventricles, and the sound of muscular con- traction. The second sound they refer exclusively to the closure of the semilunar valves by the refluent blood from the aorta and pulmonary artery. The main results of the experiments of these gentlemen accord greatly with what the writer has entertained and taught on the subject. Still, the matter is open for fresh investigation ; especially as M. Cruveilhier, from a case of ectopia cordis, carefully examined by him, inferred that the greatest intensity of the first sound is in the same situation as the greatest intensity of the second— that is, at the origin of the larger arteries ; or, in other words, that both sounds are seated in the semilunar valves. (Gazette Medicale de Paris; Aout, 1841, p. 535.) The different views on the sounds of the heart, entertained by different ob- servers, are given elsewhere. (The writer's Human Physitdogy, 5th edit. ii. 119, Philad. 1844 ; and Practice of Medicine, 2d edit. ii. 460, Philad. 1844.)] We now proceed to examine more minutely the phenomena produced by the actions of the heart, in health and disease, with the view to de- duce therefrom such diagnostic signs as they are capable of affording. It is hardly necessary to premise that the auscultatory diagnostics of car- diac diseases are founded precisely on the same principles as those which apply to diseases of the I lungs. We have certain natural sounds and movements, depending on the physical structure and natural action of the parts, and therefore of constant occurrence in the state of health. These I sounds and movements are changed from their normal character by disease, in a certain deter- minate manner, in accordance with the known laws of physics. If we are acquainted with the movements and sounds of health, and with their various relations, we can have no difficulty in Vol. I___33 w* detecting their morbid deviations. And as these deviations depend on fixed physical changes of structure, just as the normal sounds depend on the normal structure, the study of the former sounds will enable us to ascertain the existence of the morbid causes, as in the other case the sounds of health indicated the presence of the normal structure. In strictness of language, auscultation can only take cognizance of the sounds which accompany the motions of the heart. As, however, these sounds are intimately connected with the shock or impulse communicated to the side, and as this important sign is appreciated by the same organ (the ear), though not by the same sense, it has been customary to consider it along with the phe- nomena of sound and rhythm, which are strictly referable to the sense of hearing. As this arrange- ment is extremely convenient, we shall adopt it in the present article; and shall, indeed, com- mence with the consideration of the phenomenon which, in a philosophical arrangement, could not be admitted at all. I. Impulse.—This, as we have already said, is, in the state of health, always coincident with the first sound. It is not, however, exclusively con- fined to this period of time in the state of disease. The impulse may vary from the ordinary standard in different individuals in health, and in the same individual in disease : 1. in the period of its oc- currence, or its relation to the sounds; 2. in its individual character, particularly in its degree or intensity ; 3. in its sphere, or the extent of chest over which it is perceptible. 1. Although the impulse is usually synchro- nous with the first sound, and with this only, it occasionally accompanies the second sound also. This, however, is of rare occurrence, and is only met with in a particular form of disease. It has also a very different character from the normal impulse which accompanies the first sound. It is perceived, according to Laennec, to have its origin much deeper within the chest than the other stroke, and, in giving it, the heart seems to be receding from the ear. Most commonly it con- sists merely of a sort of trembling felt deep within the mediastinum ; and it is always very slight in degree when compared with the normal impulse. Dr. Hope terms this second impulse the back stroke, and considers it as in a great measure con- fined to cases of hypertrophy with dilatation ; or, rather, that it is observed more particularly in this disease when existing in a great degree. 2. There is great difference among individuals in perfect health respecting the degree of impulse. In some no impulse can be detected either by the hand or stethoscope ; in others it is imperceptible by the hand, and very perceptible by the stetho- scope ; and in some rare instances it appears on the application of the hand to be very great, at the same time that the instrument conveys only a slight impulse. These varieties depend on fixed physical causes, although they may not be readily explicable in every case. In lean subjects all movements as well as sounds are more perceptible from the greater susceptibility of the chests of such persons to vibrate, and their greater conduct- ing power. In nervous flurry, the heart acts tumultuously and not powerfully, producing rather 256 AUSCULTATION. a general commotion than impulse; hence the effect is more distinct to the hand than to the stethoscope. In general, the impulse consists simply of the sensation of a slight blow or shock, communicated to the spot on which the hand or instrument rests, sometimes sufficiently strong to produce a perceptible elevation of the part, at other times only having sufficient power to occa- sion a sort of vibration without upward movement. Sometimes the body that gives the shock appears to be of large extent, sometimes quite small. The blows are sometimes quite distinct and abruptly defined ; at other times they seem to run into each other. The causes of these differences are also well known. The brief, sharp impulse cor- responds with a sudden abrupt blow, unaccom- panied by any heaving of the heart, and indicates an organ with thin parietes. The prolonged im- pulse, with an extensive heaving movement, is the sign of thick walls, whether natural or from disease. In all cases the degree of impulse varies greatly according to the state of repose of the patient. Every kind of bodily exercise or mental excitement; in other words, every tiling which stimulates the muscular action of the heart, or hurries the circulation, augments the impulse. When causes of this kind act powerfully, they produce what may be considered as a factitious or temporary palpitation; and in such cases the impulse of a healthy heart is sometimes very great, being sufficient to elevate the ear as by a sudden blow. It is for this reason an invariable rule to depend only on such stethoscopic explorations of the heart as are made during a state of quietude both of body and mind. In this state, in healthy individuals having hearts well proportioned, the impulse is in general not very perceptible, and in a considerable proportion of cases it is quite im- perceptible. When the respiration is frequent and laborious, we must be careful not to mistake the rise of the thoracic parietes, during inspiration, for the impulse of the heart It may be stated as a general rule, that, cxteris paribus, the degree of impulse is in proportion to the thickness of the walls of the ventricles, the impulse being greater, the thicker the walls. If, then, we find a degree of impulse beyond the or- dinary standard, habitually present even during repose, we may be almost certain that there exists hypertrophy of one or both ventricles, more parti- cularly if the pulse continues of moderate fre- quency. Increased impulse, as already stated, is a constant result of increased action of the heart without any addition to its muscular substance. But in such cases the pulse (that is, the contrac- tion of the heart) is always preternaturally fre- quent. Preternatural intensity of impulse with natural frequency of action—or with very slightly increased frequency—can hardly arise but from hypertrophy of the heart Many causes, particularly those of a depressing kind, greatly diminish the degree of impulse, and sometimes entirely destroy it, when previously existing in a preternatural degree. Of this kind are bloodletting, diarrhoea, whether natural or arti- ficial, great abstinence, &c.; in such and similar states of the system, we must, therefore, be cau- tious in pronouncing against the existence of hy- pertrophy merely from the absence of impulse. Impulse also disappears, even when there exists considerable hypertrophy, upon the supervention of great dyspnoea, as in pleurisy, pneumonia, the asthmatic paroxysm, and likewise in the congested state of the lungs and heart which so generally precedes death. In all these cases perhaps, certainly in the greater number, the disapearance or diminution of the impulse depends on the natural actions of the heart being impeded by the morbid accumula-1 tion of blood in its cavities. Cases certainly occur, also, in which, from some unknown causes, an hypertrophous heart does not give any preterna- tural impulse, as well as others in which an habi- tually great impulse accompanies a thin organ. But these are merely exceptions—rare exceptions — to a general rule, which is unquestionably as stated above. The rationale of increased impulse from hypertrophy of the heart is sufficiently clear. In the first place, the organ is larger, and its ac- tions will necessarily bring it more closely in con- tact with the chest; secondly, having a greater number of contractile fibres, its contractions must be more energetic; and, thirdly, the very condi- tion of a hypertrophied muscle almost involves the fact of augmented irritability and activity. It is well remarked by Andral, that, even if we were unable to account for the anomalies now referred to, both of increased and diminished impulse, we have no reason to doubt the truth of the general proposition. It is not to be wondered at, if, in a machine so complicated, and subject to such diversity of influences, as the human body, we should meet with anomalies beyond our power of apprehension. So long as they continue to be exceptions only, and do not militate against prin- ciples, medicine need have no fear to acknowledge their existence. 3. The impulse, in health, is in general felt only in the immediate region of the heart, that is, in the space occupied by the cartilages of the fourth, fifth, sixth, and seventh ribs, or, at most over the lower half of the sternum. When this bone is very short, it is sometimes perceptible by the hand in the epigastric region. Generally speaking, the sphere of impulse is proportioned to the size of the heart, a small heart being felt over a small space, a large one over a large space. It is in some degree also proportioned to the degree of action of the organ, a heart that pulsates quietly having a less extensive sphere of impulse than one that is excited to quick and vehement action. When the heart is increased in mere muscular thickness without proportioned enlargement of its cavities, the sphere of impulse is scarcely extended beyond the space already mentioned ; hut in hy- pertrophy combined with dilatation, it is extended much beyond this, being sometimes felt very dis- tinctly under the clavicles, on the right side of the sternum, and occasionally even on the back. The impulse may be extended beyond its natural sphere by displacement of the heart; although, perhaps, in this case it would he more correct to say that the impulse is altered in its situation than that it is extended beyond its natural sphere. Such alteration of the position of the heart may be either congenital, or the result of disease. (See Heart, Displacement of the.) In this last case, the causes of the displacement are generally AUSCULTATION. 259 of such a kind as are calculated to extend the sphere of sound also on other principles, namely, from disease of other organs. In the state of health, the heart is surrounded by parts very ill calculated to convey impulse, on account of their soft and yielding nature. But if the qualities which render the parts unsuited for the trans- mission of impulse have others of a different kind substituted in their place, the extension of the impulse will be altered with the change in their conducting powers. Every disease which renders the parts adjacent to the heart more solid or more coherent, will therefore augment the sphere of impulse. Of this kind are hepatization of the lungs from acute or chronic pneumonia; com- pression of the same parts by pleuritic and other effusions, or by tumours exterior to them ; the growth of foreign bodies within the pulmonary substance, particularly of a solid kind. If, in addition, the lungs are closely united to the walls of the chest, the conduction will be still more complete. Adhesion of the pericardium to the heart occasions an extension of impulse otherwise than by simple conduction. In this case every movement of the heart sets in motion all the parts to which the pericardium is naturally attached ; and if these and the adjacent parts should chance tp be condensed by any of the causes just men- tioned, the impulse may be then very widely ex- tended. An opposite condition of the pericardium gives rise to somewhat similar results. When this sac is greatly distended with fluid, as in chronic pericarditis, the heart floating loose, as it were, in its tumultuous movements, sometimes carries its impulse to a greater distance beyond the cardiac region. Sometimes the impulse is even conveyed beyond the limits of the chest, as in the case of an enlarged liver encroaching on the thorax, and coming nearly in contact with the heart. (Med. & Phys. Journ. vol. xlix. p. 385.) The cause of the impulse communicated to the walls of the chest by the action of the heart, was formerly and for a long time considered to be the reaction of the column of blood thrown into the curved aorta, tilting the loose apex of the heart forwards. This explanation has, however, been of late questioned; and it seems, indeed, quite inadequate to explain the fact. There seems little reason to doubt that the impulse is occasioned by the muscular action of the heart itself, although there may be various opinions as to the particular movements which produce it. All that is import- ant in a practical point of view are the various relations which this phenomenon bears to the pathological condition of the heart and other organs within the chest II. Sounds of the heart.—These may be con- sidered under two heads—-first, the natural sounds; second, the adventitious sounds. A. Natural sounds.—These may be considered according to—1. their individual character; 2. their relation to the impulse and to one another; in other words, their rhythm ; and, 3. their sphere or the extent of chest over which they are percep- tible. 1 and 2. The general characters of the sounds of the heart and also their rhythm have been already given; We shall only here observe that there is great variety in individuals in respect of these characters. In some the sounds are very loud and distinct; in others they are the reverse, They also vary in their tone or key, being some- times grave or dull, and sometimes clear. The cause of these differences will presently be ex- plained. Unlike the impulse, the sounds produced by the action of the heart are almost always, if not always, perceptible in the cardiac region in the state of health. They are generally very dis- tinct as heard by the naked ear; but they are commonly perceived more accurately by means of the stethoscope. It is found that the intensity of impulse and sound depends on opposite conditions of the heart, and therefore they are never, in a state of health, present together in a great degree. The impulse, as we have already shown, is great in proportion as the walls of the ventricles are thick ; the sound is greater in proportion as they are thinner. The sounds of the left cavities of the heart are chiefly perceptible near the junction of the cartilages of the fourth, fifth, sixth, and seventh ribs; those of the right, more under the sternum. 3. In the state of health we find the impulse to be strictly confined to the region of the heart, or to its immediate vicinity. The sound, however, is much more erratic, being frequently perceived at a great distance. In certain persons, indeed, the sound seems as strictly circumscribed as the im- pulse, appearing confined almost to the point on which the stothescope rests. Such cases are, however, rare; and it is usual, even in the healthi- est individuals, to perceive the sounds over a cer- tain proportion of the exterior aspect of the chest at least; as, for instance, the lower third of the sternum, or a little to the right of this, and mid- way between the nipple and left clavicle. There are many circumstances, still within the range of perfect health, which considerably augment the sphere of the heart's sounds. The range of sound is more extensive in infancy and childhood than in adult life. It seems, also, to bear a pretty accu- rate relation to the size of the thoracic cavity, the range being much greater, cxteris paribus, when this is small than when it is large. Hence in per- sons with very narrow or contracted chests, whether natural, or from the effects of disease, constrained posture, or improper modes of dress, the range of sound may be heard over the greater part of the chest, both before and behind, and cer- tainly if the heart is naturally thin, or when the circulation is hurried by the least agitation. In women, even when well formed, the range of sound is greater than in the other sex ; it is, therefore, in general very considerably greater in them, since the natural dimensions of the chest are diminished almost universally by the com- pression of stays. The thickness of the parietes of the chest has also a considerable effect in modi- fying the range of sound ; this being very con- siderably increased by emaciation or leanness, whether natural or from disease. Perhaps the augmented range of sound intmildren and females is partly owing to the cavities of the heart being proportionally larger, and its walls proportionally thinner, than in adult males : in both the former classes of persons, the muscular system, as is well known, is less developed than in the latter. In all these cases the sound is frequently heard over 260 AUSCULTATION. the whole chest It is highly necessary, therefore, before drawing any conclusions from the range of 60und in individual cases, to ascertain the exact structure and conformation of the chest, as well as to procure a state of perfect quietude. We think it necessary to insist the more upon this point, because we believe it is one on which frequent mistakes are committed in practice; and as one or other of the various causes of augmented range is of such constant occurrence, we would say that this is one of the indications which should be most distrusted by the young auscultator. The negative indications derived from a preternaturally confined range of sound, are much more trust- worthy ; since the number of accidental circum- stances which can temporarily diminish the range in the case of persons in whom it is habitually great, is much smaller. It is an important practical precept in studying the indications supplied by the range of sound, to take into consideration the frequency of the pulse. As every cause which augments the action of the heart augments also the range of sound, we shall be naturally much more distrustful of an extensive range in cases where the pulse is quick than where it is slow, inasmuch as quickness of pulse is a very common effect of mere temporary causes, and slowness a very rare one. An extensive range of sound with a quick pulse may be frequently ne- glected, as far as relates to the diagnosis of the cardiac affection ; an extensive range of sound with a slow pulse always demands investigation, and will frequently be found to indicate disease. Exclusively of their influence in hurrying the circulation, and thereby producing a louder sound, many diseases of the chest augment the range not only of impulse, as already stated, but also of sound, merely by conducting more widely the natural sound. All diseases will have this effect, which render the organs more solid. Every form, therefore, of inflammation of the lungs will have more or less this effect, which will be the greater, the nearer the affection approaches to complete hepatization. Compression of the lung from pleu- ritic effusion will act in the same manner; and in this case, as in the preceding, the points on the surface of the chest on which the sounds will be most audible, will depend on the position of the indurated or compressed portions within. All solid depositions in the pulmonary substance will have a similar effect, proportioned, generally speaking, to the sum of their mass. The most common form under this head is phthisis ; and if one had previously ascertained in health the range of sound, some idea might be formed of the amount of tuber- cular deposition from the range in the state of disease. Even when the tubercles have suppu- rated, and have left large empty cavities in the lungs, the transmission of sound continues to be greatly facilitated,—the solidity of the walls of the excavations, and the compressed state of the sur- rounding pulmonary substance, more than com- pensating the actual* loss of substance from the disease. It is thus, as Laennec observes, that in the case of tuberculous excavations of the right lung, we hear the sound better under the right clavicle and in the axilla, than on the left side, and sometimes even better than in the region of the heart itself. The sounds of the heart are always in some degree masked by the respiratory sounds, and in proportion to the loudness of these. In the cases of disease in which there is a very loud rhonchus, the sounds are completely obscured on the anterior part of the chest; it becomes therefore proper, in such cases, in order to perceive the precise nature and extent of the sounds, to observe them in the intervals between inspiration and expiration ; and these may he prolonged designedly by the patient, if it is found necessary. In extending itself from the cardiac region over the rest of the chest, the sound of the heart almost always follows a fixed tract, being heard successively, according to Laennec, in the fol- lowing places—the left side of the chest before; the right side before; the left side behind; the right side behind. " In these cases," says Laen- nec, " the intensity is progressively less in the succession mentioned. For instance, it is less under the right clavicle than under the left; it is somewhat less on the lateral parts of the left side than under the clavicle; it is still less per- ceptible on the right side laterally; and much attention is commonly requisite to enable us to hear the pulsations at all in the back; particu- larly the right side. This succession has ap- peared to be almost constant, and may be taken as an index of the extent of pulsation. For in- stance, if this be perceptible on the right side, we may be assured that it will be equally so over the whole sternum, under both clavicles, and over the left side; but we are not sure that it will be so on the back. But if it be percepti- ble on the back on the right side, we may calcu- late on its being still more audible on every other part of the chest" As this is the succession of health,— and almost invariably,— it is obvious that any deviation from it, at least any great de- viation from it, may be considered as produced by disease, and may thus become a sign of some importance. For instance, if the sound is much more audible on the right back than on the left back, or even on the left side, we have great rea- son for believing disease to be the cause of this anomaly ; and the circumstance may tend mate- rially to elucidate the diagnosis in doubtful cases. If the heart retains its natural position, some change must have occurred in the contents of the right side of the chest, to occasion this in- creased power of conducting sound. When the sounds of the heart are heard much beyond the usual sphere of health, in cases in which the chest seems pretty well formed, and in which none of the causes producing an exten- sive range can be detected, the individual rarely enjoys good health. Although he may not have any other of the more ordinary signs of disease of the heart, it will be found that his system is a feeble one, and obnoxious to many morbid im- pressions. " In examining him attentively," says Laennec, « we shall discover indications of that cachexy peculiar to some diseases of the heart; and we shall find that, if he has not formal dys- pnoea, his respiration is, at least, shorter than usual; that he is more easily put out of breath, and more subject to palpitation. This state, he adds, which is that of many asthmatics, may re- main stationary many years, and does not always AUSCULTATION. 261 prevent the attainment of an advanced age." Our own experience would lead us to consider such a state of heart which is generally conge- nital, if not the cause of many other morbid states of common occurrence, as, at least, a cir- cumstance greatly predisposing to them, and aggravating others originating from different causes. It tends powerfully to the production of venous plethora and its numerous train of evils; it leads directly to a defective distribution of blood in the extremities and on the surface, and to a superfluous store in the head and larger viscera; it is a very common cause of head-aches, particularly such as are commonly termed nervous, and eventually leads to apoplexy and palsy. Such persons have almost always cold extremi- ties. We are even of opinion that that complex disease, scrofula, if not occasioned, is at least frequently hastened in its development, and is always aggravated, by the concomitance of a feeble heart. B. Adventitious sounds.—Besides mere changes in the degree, extent, and relative succession of the sounds, their very character may be altered; new sounds may be superadded to the old, or may entirely take the place of these. The most common and most important of these changes is the conversion of the usual sound into one re- sembling the puff of a pair of bellows, or the rough, grating sound produced by the action of a file, rasp, or saw upon wood. The bellows- sound, termed by Laennec bruit de soufflet, most accurately resembles the puffing of a small pair of bellows, as employed to blow the fire. The new sound usually takes the place of the natural one; sometimes the two are conjoined; it may be present during the first and second sound, or only during one of these. The saw-sound, or rasp-sound, bruit de scie, bruit de rape, of Laen- nec, is as happily named as the former variety, as nothing can be more precise, in many cases at least, than the resemblance between the sounds of the heart and those to which they are com- pared. The notion of smoothness is always conveyed by the bellows-sound, and that of rough- ness by the saw-sound. Yet they gradually pass into each other, from the slightest deviation from smoothness in the bellows-puff through all the intermediate gradations of roughness produced by a very fine-toothed saw, a wood-rasp, up to the harshest notes of a large-toothed saw. In many instances these anormal sounds of the heart imitate, with singular accuracy, both in their individual qualities and in the regularity of their recurrence, the sounds produced by a car- penter sawing through a small piece of wood at a short distance from the hearer. The loudness of these sounds is frequently very great, as heard with the stethoscope, being sufficient almost to startle one on first applying the ear to the instru- ment. Like the bellows-sound, that just'de- scribed may occupy the place either of the first or second sound; but it accompanies the former much more frequently than the latter. The sound of the saw or rasp is often heard at a gceat distance from its site, like the natural sounds of the heart; the bellows-sound is for the most part confined to the place where it originates. Both of them, however, are occasionally perceived in the arteries, at some distance from the heart. The bellows-sound, in particular, is frequently ob- served at a considerable distance from the heart, and even when no such anormal sound can be detected in that organ. When the saw-sound exists in the heart, it may always be traced along the arch of the aorta to the carotids and subclavian arteries. Laennec has noticed a singular variety of the bellows-sound, in which the successive tones are modulated into regular musical notes. He therefore terms it the musical bellows-sound. The causes of these morbid sounds have been investigated with much care by Laennec and his followers. At first Laennec considered them as exclusively the result of contraction of the valvular orifices from organic disease. Subsequent expe- rience, however, led him to conclude that they may exist without any discoverable change in the orifices or valves, while such change may exist without their concomitance; and he at length adopted the opinion that all the varieties were owing to a spasmodic contraction of the parts in which they originated. As a general statement of the fact, this opinion is certainly erroneous. Indeed it now seems fully established that the im- mediate causes of all these sounds are certain anormal motions or currents produced in the co- lumn of blood, whereby this, which usually glides on smoothly and silently, is thrown into sonorous vibration. Whatever produces the movements in question may produce the sounds; and one of the causes may certainly be that which Laennec sup- posed. A much more frequent cause, however, is permanent alteration in the caliber of the canals through which the blood passes, by some organic change effected in them; and by much the most common cause is contraction of some of the ori- fices of the heart. The bellows-sound appears to originate in much slighter causes than the sound of the rasp or saw, and is, therefore, of less value as a sign of disease. Laennec ascertained that pressure on an artery will reproduce the bellows-sound after it had ceased; and it is now known that the same pressure will frequently produce it in an artery where it had not before existed. It is very con- stantly present in cases of bronchocele of consi- derable size, and gradually disappears as the tumour is absorbed under the use of iodine. It is also present in the arteries of the impregnated uterus. It is frequently removed, when strongly marked in the heart, by venesection. It cannot, there- fore, be admitted as a sign of organic disease, al- though it is by no means to be disregarded among the symptoms of diseases of the heart, more espe- cially if it is permanently present. The sound of the saw or rasp is of less frequent occurrence than the simple bellows-sound; al- though there is .no reason to believe that their causes differ otherwise than in degree. Slighter causes suffice to produce the bellows-sound. The sound of the saw or rasp is occasionally perceived in the carotid and subclavian arteries; it is also observed in the arteries of the enlarged thyroid gland, and in those of the impregnated uterus. It is, however, most constantly observed in the heart, in the case of a contracted state of the orifices. In reference to these adventitious sounds, col- 262 AUSCULTATION. lectively and individually, we think the following conclusions may be deduced from the considera- tion of them:— 1. The source of the sounds is some impedi- ment to the usual current of the blood, from some physical alteration in the channel through which it passes, whereby such vibrations are excited in the column of fluid as to give rise to audible sound. 2. The alteration in the channel may be mere- ly temporary, and produced in parts possessing a healthy structure, from nervous causes, from want of the natural harmony of proportion between the size of the channel and its contents, and pro- bably from other unknown causes. The more common cause, however, is some fixed physical alterations in the channels conveying the blood ; either a contraction or enlargement of caliber, or some other deviation from the natural structure, whereby the current is more or less impeded or disturbed. 3. We are not justified, by the mere presence of any of these sounds, in concluding that organic disease of the valves or valvular orifices exists. 4. If the morbid sounds disappear after repose, bloodletting, or other form of depletion, or with- out any evident cause, we may suspect that they originate in mere functional disorder; and the probability of this opinion will be increased in proportion to the period of their absence. 5. If they are not removed by these or any other causes, or if they are removed for a very short period only, or are merely lessened in de- gree, we may conclude that they originate in dis- ease of the valvular orifices; and this conclusion will be still further strengthened if there exist other symptoms of diseased heart. 6. The probability of organic disease is in- creased in proportion as the character of the sounds approaches that of the sound of the saw or rasp. 7. The sounds produced by valvular disease become much weaker when the contraction of the orifice is extreme than when it is moderate, a certain extent and force of current being requi- site to produce them in the highest degree. Dr. Hope says that he has often found that when the orifice was reduced to a crevice of two or three lines in width, no sound whatever was produced. 8. The following is a brief sketch of the ra- tionale of the morbid or anormal sounds resulting from valvular disease, for which we are indebted to the able physician just named. (a.) When the aortic orifice is contracted, an adventitious sound, or morbid murmur, accompa- nies the ventricular systole and first sound; and when the valves, not closing accurately, permit regurgitation from the aorta, a morbid murmur accompanies the diastole and second sound also; but this last, when it occurs, is extremely slight and brief, as the influx of blood from the auricle, during the diastole, almost instantly puts an end to any regurgitation capable of producing sound. (b.) When the pulmonic orifice is contracted, the effects are the same ; but disease of the valves on this side of the heart, as will be shown in an- other place, is comparatively very rare. (c.) When the mitral orifice is contracted, a morbid murmur accompanies and sometimes en- tirely supersedes the second sound, being occa- sioned by the passage of the blood from the auri- cle into the ventricle during the diastole of the latter. When the valve, not closing accurately, admits of regurgitation, a murmur accompanies the first sound, and this is sometimes excited by a degree of disease insufficient to produce it dur- ing the second. (d.) When the tricuspid orifice is contracted, the results are the same as in the last case. There is yet an adventitious sound, of a differ- ent kind, and originating in a totally different cause, which deserves to be noticed. This is the sound which Laennec compared to the creaking of the leather of a new saddle, and which he termed cri du cuir. At first he conceived this sound to be connected with pericarditis; but he afterwards gave up this opinion, and considered it as owing to accidental circumstances not of a mor- bid kind. Other observers, however, have been led to adopt Laennec's first opinion ; and several cases have been published which render it ex- tremely probable that this peculiar sound is pro- duced by the friction of the heart against the peri- cardium, when one or both have lost their polish from the effusion of solid lymph with little or no serum. If this opinion be correct, the sound ought to present itself in most cases of pericarditis at some period of their course ; and it should always be present when there is considerable albuminous exhalation with little or no serum.* This sound, both in its character, causes, and its value as a sign, is precisely analogous to the bruit de frofte- ment, noticed in a former part of this article. The sounds of the rasp or saw are very fre- quently accompanied by a phenomenon which, like that of impulse, can only be brought under the head of auscultation on a principle of conve- nience, since, like impulse, it is appreciable by the sense of touch, not of hearing. This is the phe- nomenon termed by Corvisart bruissement, and by Laennec fremissement cataire, terms which it is not easy to render in English, nor yet to find good substitutes for. It is a peculiar vibration or thrill communicated to the finger laid upon the heart or artery where it exists, and which resem- bles pretty accurately the gentle tremor communi- cated to the hand of a person while stroking the head of a cat when purring. When existing in the region of the heart, " the thrill" is identical with the sound of the saw, rasp, or bellows : the difference being in the sense which perceives, not in the thing perceived. If we could always say, from the character of the thrill, with which of the two sounds of the heart it is identi- cal, it would be more valuable as a sign than it is. It is proper to observe that we do not always hear any of the sounds when we feel the vibration; nor, conversely, do we always feel the vibration when we hear the sound. This, however, is not any proof that both do not spring from the same physical cause. The cause may exist in a degree sufficient to excite one sensation and not the other; just as we may feel or see the vibration of a mu- sical string after the ear has ceased to hear any sound from it. It is, therefore, we conceive, with- * Colin. Exploration de la Poitrine.—Theses dela Fa- culte de Med. No. 175. - De I'Auscult. Mod. 3eme edit. tool. in. pp. 66, 262. notes. AUSCULTATION. 263 out good grounds, that Laennec considered the separate existence of these phenomena as proofs of their non-identity. (See Dr. Corrigan's Expe- riments in the Lancet) Dr. Hope says that, although resulting from the same causes as the morbid sounds, the purring tremor or thrill re- quires, caeteris paribus, a stronger current for its production ; for which reason it less frequently accompanies the passage of the blood from the auricles into the ventricles, than from the latter into their respective arteries, or into the auricles by a retrograde movement Even in the latter cases, Dr. Hope adds, it is seldom strong unless the ventricle be hypertrophous, or the circulation hurried. Laennec says the thrill is almost always confined to the left side of the heart; although it is occasionally extended much beyond this. The hand must be pressed very firmly upon the heart, in order to feel it well. When existing in the arteries, a middling degree of pressure enables us to perceive it best; a very slight one does not attain it a strong one abolishes it It is some- times continuous, sometimes renewed by the arte- rial pulse; sometimes it is confined within the caliber of the artery, sometimes it is perceived considerably beyond. In no case have we had occasion to observe the thrill more constantly and distinctly than in the thyroid arteries in cases of large bronchocele. Auscultation of the Heart in the Foetus. Diagnosis of Pregnancy. M. Mayer, of Geneva, appears to have been the first who applied the tests afforded by auscultation to discover the existence of the foetus in utero. In the Bibliotheque Universelle for November, 1818, it was stated that this gentleman had ascer- tained that the sounds of the foetal heart are read- ily perceptible by applying the ear to the abdomen of the mother. The subject was afterwards pro- secuted, with the aid of the stethoscope, by M. Kergaradec, and with additional results indicative of its importance; and the following facts, verified by numerous auscultators in this country and on the continent are now as weu" ascertained as any detailed in former parts of this article. There are two auscultatory signs of the pre- sence of a living foetus in the womb—1. the dou- ble sound of the heart; and, 2. the existence of the bellows-sound in the placental arteries, or ra- ther, in the uterine arteries immediately connected with the placenta. 1. The pulsations of the foetal heart may be perceived as early as the fifth month, or between that and the sixth. They are characterised by the double sound of the adult heart and by the pecu- liar rhythm of this, which can never be mistaken for any other sound. The sounds, when compared with those of the adult heart, examined in the cardiac region, are extremely feeble ; but they are, when at all perceptible, perfectly distinct. They are distinguished from all arterial pulsation of the mother by the duplex rhythm, and by the extreme frequency of their recurrence. The fretal pulsa- tions are generally more than double that of the mother. The sounds are found to be much more distinct at one time than another, in the same place, and in different places at different times. These variations no doubt result from the varying position of the foetus, and from its relation to the uterine parietes. The sounds will be much more distinct when the trunk of the foetus is in direct contact with the uterus, and, most of all, when the anterior part of its chest is applied opposite to the spot on which the stethoscope rests. When the whole body of the child is removed from that side of the uterus over which the instrument rests, it is doubt- ful if the action of the heart can be at all perceiv- ed. The more copious is the liquor amnii, the less perceptible, cxteris paribus, will be the foetal sounds. The space over which the sounds may be heard is generally pretty extensive, being, in- deed, frequently the greater portion of the region occupied by the uterus. It is, however, in gene- ral, easy to discover the point which is nearest to the source of the sounds, by the decreasing and increasing intensity of these, as our examinations recede from or approach towards one particular spot. In general, the pulsations of the foetal heart vary from 120 to 160 in a minute. In one case noticed by Dr. Ferguson, (Dublin Trans, vol. i. New Series,) the relative frequency of the mo- ther's and child's pulse was singularly reversed; the former being 100, while the latter was only 20. We have met with no similar instance on record. 2. The second auscultatory sign of the presence of the foetus has been termed the placental sound or placental bellows-sound, likewise the utero-pla- cental soufflet. It was first noticed by M. Kerga- radec, and although a less absolutely certain indi- cation of pregnancy than the sound of the foetal heart, it is a sign of great importance. Although termed placental, there can be little doubt that the site of the sound is in the uterus, in the enlarged arteries which supply the placenta.* The sound assumes, at different times, all the character of the bellows-sound of the heart. It becomes percepti- ble about the fourth month of gestation, and is then more distinct than at a later period. Dr. Ferguson says that he has not observed any vari- ety of the sounds to be peculiar to particular stages of pregnancy. In the early stages, Laen- nec describes the sound as resembling that which is produced by discharging a blast from a pair of bellows into an empty bottle. At a later period, the sound is duller, more diffused, and no longer conveying the impression of being limited to the caliber of a single artery. It assumes all the vari- eties of the valvular sounds of the heart from the simple bellows-sound to the sound of the rasp or saw. Dr. Ferguson says that the most constant variety " is a combination of the bellows or the sawing with the hissing sound, commencing with one of the former, and terminating with the lat- ter." These sounds are confined to a much smaller space than those of the foetal heart. The point where they are most audible is always fixed in the same person, but varies in each individual. In some, the sound can only be detected' in a single 6pot a few inches square. There is no particular part of the uterine tumour in which the sound * A striking analogical instance is afforded by the thy. roid arteries in bronchocele, no!iced in a former part of this article. Query, will the same result be obtained in active hypertrophies of other parts of the system 1 264 AUSCULTATION — BARBIERS. may not be found; but Dr. Ferguson says that he has found it most frequently in the iliac regions. The placental sound is always isochronous with the pulse of the mother, and is unaccompanied by any degree of impulse. Whatever be the precise mode of production of this sound, there can be no doubt that it has its seat in the enlarged vessels of the uterus in that portion of it immediately connected wtth the placenta. This is proved by the following facts : 1. The sound, as already stated, is confined to a fixed space in each individual. 2. This spot is ascertained, by examination after delivery, to be always that to which the placenta had been at- tached. 3. That the sound is not seated, at least exclusively, in the placenta is proved by the fact that the sound is still audible for a short period after the placenta is detached. 4. It ceases im- mediately upon the contraction of the utero-pla- cental arteries, as is proved in cases of death of the foetus without delivery, and by its instantane- ous cessation on the contraction of the uterus after delivery. 5. It is in all cases synchronous with the mother's pulse. There seems little ground for believing, with Dr. Kennedy, (Dublin Trans.) that the placental arteries themselves have a share in the production of the sound, any farther than by their action promoting that of the uterine arte- ries. The character of the sound is changed by the cessation of the foetal circulation, as by the removal of the placenta, the death of the fcetus, or tying of the cord, (Dr. Kennedy denies M. Ollivry's statement that it is immediately extin- guished,) the sound becoming " abrupt, of short continuance, and wanting the lengthened termi- nating whiz observed in the perfect sound." This may easily be explained by the change necessa- rily produced in the uterine circulation by the removal of the foetal circulation, without suppos- ing that the placental arteries had any direct share in its production. Great care and attention are requisite on the part of the auscultator in investigating these phe- nomena. The sounds being very feeble, perfect silence is necessary during our explorations, and we must be very careful not to confound the sounds with others which may exist at the same time, such as the sound of the mother's heart (which is often distinctly audible in the region of the uterus), of the intestinal movements, and the sound of muscular contraction produced in com- pressing the abdomen with the stethoscope. As the phenomena are sometimes intermittent, or, at least, not always perceptible, we must not deny their existence because they are not discovered on the first examination. The sounds may be heard almost as well by the naked ear as the stethoscope ; but to all who are accustomed to use this instrument, there are numerous and very obvious reasons why it should be preferred. It is, however, well that practition- ers should be aware that the phenomena may be detected by any one, whether a practised auscul- tator or not. Different practitioners make the patients adopt different positions during exploration. In many cases the sounds are heard very distinctly while the patient is seated in a chair in her ordinary dress; but it is always preferable, when it can be done, for the patient to assume the horizontal pos. ture, and remove her stays and thick petticoats. The presence of the solid stays is particularly objectionable, as they are apt to convey the sounds of the mother's heart from the chest downwards. No one who is aware of the frequent and great difficulties experienced by practitioners in detecting pregnancy, and of the vast importance of doing so in some cases, will have any doubt of the great value of the signs now described. They are al- most as certain as the perception of the foetal movements, and more certain than the touch ; and they possess a very great superiority, in point of convenience and delicacy, over the latter. It is true, they have not been detected in some cases of pregnancy ; it is probable that, owing to some peculiar idiosyncracy, they may never manifest themselves in certain cases; but ample experience proves that their absence is a circumstance of extreme rarity. Their absence, therefore, must not be considered as an absolute test of the non- existence of pregnancy; although their presence may be looked upon as the reverse. Here, as in every other case in which auscultation is applied, we have all the other signs to guide our judgment in the instances where the foetal and placental sounds are not detected ; while in the vast major- ity of cases, we have an additional sign, of almost infallible accuracy. It cannot therefore, be de- nied that this form of physical diagnosis has con- ferred even on puerperal medicine a boon of im- mense value. [Subsequent auscultators have not confirmed the value of the utero-placental murmur. Ute- rine and other tumours than the gravid uterus have unquestionably produced it. (See the Art Pregnancy ; also, Bouillaud Traite Clinique des Maladies du Coeur, Paris, 1835; Hope on the Diseases of the Heart, Amer. edit by Pennock. Phi- lad. 1842, p. 153; Raciborski, Manual of Ausculta- tion, by Fitzherbert, p. 145, Lond. 1835.) In a case of fibrous tumour of the uterus, the writer heard it distinctly, (Dunglison's Human Physio- logy, 5th edit, ii. 423) ; and Prof. R. M. Huston (Amer edit, of Churchill's Theory and Practice of Midwifery, p. 136) states, that he is satisfied he heard it in a similar case, and, also, in one in- stance from the presence of an enlarged ovary. The murmur is produced by the pressure of the tumour on the large vessels of the mother.] This article has extended to so great a length as to prevent us from offering some general re- marks on the actual and comparative value of auscultation as a diagnostic measure. We may probably have another opportunity of doing so. John Forbes. BARBIERS. This is a variety of paralysis, chiefly prevalent in India. Sauvages thus defines it: « Motus gradientium genu retrahens cum tre- more, formicationis sensu, vocis raucedine. India familiaris." Linnaeus defines it: " Partium tre- mor, genuum contractura, stupor, raucedo." Sagar adds to the definition of Sauvages," Stupore dolo- rifico artuum." Dr. Aiken arranges the disease as synonymous with "contractura." Bontius describes barbiers well, but he gives it also the name of beriberi; and Dr. Mason Good has com- pletely confounded the two diseases ; it is of im- BARBIERS. 265 portance therefore that they should be discrimi- nated. The leading features of beriberi are uneasiness with partial loss of power of the lower extremities, obstructed respiration, and general oedematous in- tumescence. Beriberi is commonly an acute dis- ease. Barbiers is characterized by pain, numb- ness, and partial paralysis of the inferior and superior extremities : sometimes the vocal organs are similarly affected. Barbiers is generally a chronic disease. Bontius describes the disease as " a species of palsy, or rather a tremor; for at the same time that it impairs the sensation of the feet and hands, sometimes even of the whole body, it induces a trembling. It is more especially the product of a rainy season. In general the disease invades slowly ; under particular circumstances it attacks suddenly. Among the chief symptoms of this disease is a lassitude of the whole body ; the mo- tion and sensation, especially of the feet and hands, are languid and depraved ; and for the most part a titillation is felt in these parts, similar to what seizes them in cold countries in the win- ter, but with this difference, that the sensation in barbiers is more painful : the speech is sometimes so much obstructed that the patient can scarce pronounce a syllable articulately." The translator of Dr. Bontius's work states that barbiers " is most violent and frequent on the Malabar Coast, where (especially in the months of January, February, and March,) it attacks those who unwarily sleep exposed to the land winds which issue every morning about sunrise from the neighbouring mountains : suddenly seizing them with a painful sensation in the periosteum of the arms and legs. In some persons the pain abates as the day advances and the air becomes warm ; but in others it continues for a considera- ble time, attended with a weakness of the knees and an uneasy sensation in the calves of the legs and soles of the feet, especially on any attempt to walk. It is scarcely ever cured by medicine till after the shifting of the monsoon, unless the pa- tient be removed to the coast of Coromandel, or to any place to the eastward of the Baligat moun- tains, where by the changes of the air they quickly recover." Dr. Lind, in his account of the diseases inci- dental to strangers in different parts of the world, says, " Barbiers is a species of the palsy, a disease most frequent in India. It distresses chiefly the lower class of Europeans, who, when intoxicated with liquor, frequently sleep in the open air ex- posed to the land winds. Its attack is generally sudden, and entirely deprives the limbs of their motion; sometimes only part of them." The following is Mr. Marshall's account of the disease, (Notes on the Medical Topography of Ceylon :) " For the most part it commences with pain in the muscles of the thighs and legs, parti- cularly of the bellies of the gastrocnemii. This uneasiness is usually attended by a general numb- ness of the extremity and an imperfect command of the powers of locomotion. Sometimes the pa- tients describe their sensations to be as if hot water or sand was running over the affected parts; at other times they complain of a sense of formi- cation accompanied with a pricking kind of pain. Vol. I. —34 x In some cases the hands and forearms become similarly affected. I never saw a case where the disease was confined to one extremity. In gene- ral there was but little difference in the degree of the affection of the extremity of one side from that of another. In one case the muscles situated on the back part of the neck became affected, and eventually the powers of articulation were much impaired. This last symptom admitted of partial alleviations. The appetite, for food is seldom much impaired during the early stage of the dis- ease. " When the disease has made considerable pro- gress, the patient is unable to walk steadily. Stand- ing or walking in general greatly aggravates the uneasiness of the limbs. The patients have an infirm tottering gait, and those whose hands are affected lose the power of feeding themselves. They seldom enjoy sound sleep, although they seem to labour under a sluggish inactivity and an unwillingness to exert themselves. " The progress of the disease is sometimes pro- tracted to a period of several months. As the complaint advances, the patients express their sensations of the affected parts to be as if they were dry or dead, and almost entirely without feeling. Loss of appetite, indigestion, and ema- ciation soon follow ; the extremities lose the natu- ral temperature; the exterior muscles become paralytic, while the flexor muscles seem to have some force, by which means the joints (particu- larly the joints of the fingers) become contracted. The pulse is frequent, thready, and fluttering; the vital functions greatly impaired; and even- tually death supervenes." " The general remote causes of this disease appear to be cold and moisture applied to the body, intoxication, and the excesses and irregu- larities consequent on inebriety ; violent exercise in the sun, lying down in the open air during the heat of the day; exposure to the cold chilling dews of the night, and particularly by going to sleep in this situation; suddenly obstructed perspiration, by exposing the body but partially covered to a current of cold air; long fasting, and perhaps every circumstance which exhausts the human frame." Horses and dogs are sometimes liable to a simi- lar paralytic affection of the extremities, in India, which is universally ascribed to the land wind : they rarely, if ever, completely recover. The case of spasmodic disease described by Dr. Bostock in the Transactions of the Medico-Chi- rurgical Society, vol. ix. seems to have been an affection nearly allied to, if not the same as, the disease now under consideration. The patient, who was in the middle of life, was first attacked with achings in the lower limb on one side, ac- companied with a difficulty and irregularity of motion which soon extended to the other side, and then gradually to the throat, so as to impede deglutition, except with great pain and severe exertion. The larynx next became affected so as to prevent speech, and afterwards the muscles on the back of the neck. The limbs were rigid, so that they were both bent and straightened with difficulty. The intellectual powers were at lengtn affected and weakened ; the failure of understat- ing gradually increasing, principally showing itself 266 BATHING. in paroxysms, during one of which the patient died. No cause of the disease could be traced before death, nor did dissection discover any or- ganic change calculated to account for the symp- toms. For the treatment of this affection, see Paralysis. J. Scott. BATHING. In its most comprehensive sense, the term bathing means the immersion, for spe- cial purposes, of the body, or a part of it, in a medium different from that in which it is com- monly placed. Any substance which constitutes this medium, when considered only in relation to the special purpose, is, in medical language, termed a bath. A great variety of materials has been employed to form baths, the enumeration of which in this place would be of little practical utility, however it might show literary research. In the present article we shall confine our observations almost entirely to baths composed of water, watery vapour, and air. We shall commence with the fluid water bath, as being that in most general use, and by far the most generally useful. The most important cir- cumstance respecting this bath, and indeed other baths also, is its temperature. To the considera- tion of this, therefore, we shall first direct our attention. The range of temperature within which water in a liquid form has been employed for baths, includes about 80° or 90° of Fahrenheit's scale, viz. from 33° up to 112° or 120°. A lower degree, for obvious reasons, cannot be used ; and as no therapeutical indication can ever require a higher, we need not extend the scale in this direc- tion, although baths of even a higher temperature than 120° may occasionally have been had re- course to. Various subdivisions of baths, according to their temperature, have been adopted by writers on this subject—all the subdivisions being founded on the presumed difference of effect of the bath at particular temperatures. It is obvious, how- ever, that every classification of this kind must be, in some degree, arbitrary; it being utterly impossible precisely to limit the effects of any class of agents upon a subject like the living body, whose properties and susceptibilities are perpe- tually varying in the same individual at different times, and differ extremely in different individuals at the same time. In this respect bathing is pre- cisely like every other therapeutical agent We have the means of calculating with certainty the elements of one side of the equation only; the result therefore, cannot be otherwise than uncer- tain. As, however, in the case of medicines, ex- perience has enabled us to establish an approxi- mation towards a medium standard of results, in calculating their effects on men in general, so, in like manner, we have obtained certain averages in the case of bathing. And although, as we have said, the conclusions can, at best, be viewed as mere approximations, still the knowledge of them is of great utility in practice. They must, at all events, be employed as convenient expres- sions of known facts by those who would com- municate information to others. The simplest and most natural division of baths is into cold and hoi; the former comprehending all those which communicate the sensation of cold, the latter all which occasion the feeling of heat. Although, for reasons above stated, it is impossible to fix the degree which shall form the boundary between the two classes of sensations, we shall nevertheless, on the ground of practica] convenience, assume such a precise limit Gene- rally speaking this boundary will be found between the 84th and 88th degree of Fahrenheit; and although well aware that this range is sufficiently small, we shall still further abridge it by naming the intermediate degree of 88 as the precise limit, denominating all baths of a temperature below this cold, and all above it warm. In subdividing these two sections of baths ac- cording to temperature, we would propose the fol- lowing arrangement to the practitioner, as one founded on practical indications, and therefore likely to be useful,—leaving it always to be under- stood that, in fixing the precise boundaries by indi- vidual degrees, we are influenced more by motives of convenience than from any belief that these are the exact and true limits of the different classes of baths :— 1. The cold bath........from 33° to 60° 2. The cool bath,........... 60° to 75° 3. The temperate bath....... 75° to 85° 4. The tepid bath,.......... 85° to 92° 5. The warm bath,......... 92° to 98° 6. The hot bath,........... 98° to 112° OF COLD BATHING. §1. Of the Phenomena and general ope* ration of the Cold Bath. When a person in health first enters a bath of cold water, he experiences a sensation of cold pro- portioned to the lowness of the temperature, and a sudden impression on the nervous system, usually termed a shock, proportioned, cseteris paribus, partly to the degree of cold, and partly to the sud- denness of the immersion. Frequent concomi- tants, if not universally constituent parts of the shock, are, a greater or less degree of shivering and convulsive anhelation, and a confused mental feeling of surprise and apprehension. If the tem- perature is very low, these sensations are propor- tionally vivid, but they are experienced in some degree at all temperatures below that conveying the feeling of warmth. Almost immediately after the shock, the feeling of cold vanishes and gives place to one of a different kind. This gradually increases and becomes speedily diffused over the whole frame, the unpleasant sensations being suc- ceeded by others of a decidedly pleasurable kind. The water almost ceases to be felt, or is felt as communicating a sensation of warmth rather than of cold. If the immersion, however, is prolonged, this sense of warmth gradually decreases ; but if the system is at all vigorous, and the temperature of the water not extremely low, the renewed sense of cold is, for a time, rather pleasant than otherwise, the individual feeling as if the external impression were more than counterbalanced by an active force within, of an opposite kind. After a time, however, longer or shorter according to the state of the system and the temperature of the water, the sense of agreeable coolness is succeeded by one of actual cold ; more permanent tremors BATHING. 267 or ahudderings come on ; the extremities feel be- numbed, and the whole body gradually becomes languid, exhausted, and powerless. No second glow ever succeeds this second chill; but the feel- ing of cold, numbness, general discomfort and debility increase with the continuance of the im- mersion. The face and whole surface of the body become pale and shrunk, and obviously reduced in size, as is familiarly evinced by the falling off of rings from fingers on which they had fitted tightly ; the pulse becomes smaller and more feeble, and frequently slower than natural; there is a feeling of oppression on the chest, a disposi- tion to pass urine, and the sense of chilliness gradually increases to a strong and general shiv- ering. If the individual leaves the bath before the su- pervention of the second access of shivering, or before this has continued long, he generally expe- riences, on dressing, a renewal of the reaction which had followed the shock of immersion, and this having now nothing to counteract it, becomes more vivid and permanent The pulse becomes fuller and stronger than before immersion; the face, lips, and whole skin not merely recover the colour and warmth and plumpness which they had lost, but are actually enlarged beyond their habitual state ; the rings, which during the chill had dropped from the fingers, now fit tighter than before the bath; all sense of oppression in the chest and head, and of general languor vanishes, and to this succeed an exciting feeling of inter- nal buoyancy, and an agreeable consciousness of animal power. The above is a brief account of the principal phenomena usually produced by the bath of cold water as used for medical purposes. On proceed- ing to analyze them, they appear to admit of a ready division into two classes, according as they flow more or less directly from the action of the bath — the first comprehending the phenomena usually included under the term shock, the second those included under the term reaction ,• and it seems necessary, with a view to the practical ap- plication of the bath as a remedy, to enter some- what more into detail respecting them, and also briefly to notice their physiological causes, and their therapeutic operation. I. The shock. — Although it is impossible to separate entirely, either speculatively or in prac- tice, all the phenomena included under the name of shock, we can still see that the system is affected by it in various ways. 1. The application of the cold water to the surface produces an immediate and very powerful influence on the economy through the medium of sensation. The whole nervous system seems suddenly impressed, and as if about to yield be- neath some hurtful power; but, in general, before any of the important functions have become ma- terially disturbed, the conservative energies are roused to successful resistance. In certain states of the body, however, the im- pression is found to be too powerful for the nerv- ous system; and there is either no reaction, or this is too feeble to produce any useful results. A complete and prolonged depression of the pow- ers of life may be the consequence, or even life itself may be extinguished. Numerous instances are known of individuals being killed by the cold bath, in this way. Such persons have commonly entered it when they were exhausted by bodily exertion and long-continued perspiration. 2. Refrigeration, to a certain extent, must of necessity result immediately from immersion in the cold bath. This effect must always be con- joined with the former. Caeteris paribus, it is proportioned to the lowness of the temperature, and the duration of the immersion. 3. There is an immediate retrocession of the fluids from the surface of the body to the internal parts. The bath produces this effect partly through the nervous impression excited by it; partly by the contraction of the whole superficial capillaries from refrigeration, forcing their contents inwards; and partly through the mechanical compression produced by a denser medium. 4. The cold water produces, to a certain extent, a condensation of the tissues with which it comes immediately in contact, partly by the physical abstraction of heat, and partly through a vital im- pression on the organization. The contractions of the fingers, scrotum, &c. are obvious instances of this effect. Parts not in contact with the refri- gerating medium also contract, in sympathy with those which are. All the effects now mentioned are necessarily present in every case, but their relative intensity may vary infinitely, according to the condition of the subject, the mode of applying the agent, &c. The predominance of the one or the other class is of great consequence in a practical point of view ; and it is important to know that the administration of the bath may be so regulated as to produce this particular effect. II. Re-action.—The almost instantaneous result of the shock is the excitement of the nervous sys- tem to increased activity, in virtue, no doubt of that general principle of self-conservation bestowed, l in a greater or less degree, on all living organized beings. The retropulsion of the fluids from the surface upon the internal organs and large vascu- lar trunks, producing mechanical distension, and | probably also vitally stimulating the parts, unites its effects with those resulting from the direct con- servative efforts of the nervous power. The cen- tres of vital energy, the brain and heart, are roused; the latter organ re-acts with fresh vigour on its contents, and the blood is once more propelled through the whole capillary system, more particu- larly of the surface, carrying with it life, heat, and renovated action. As the effects of the cold bath, considered as a medical agent, are greatly varied according to the mode in which it is applied and the condition of the individual at the time he employs it, it is no great wonder that considerable differences of opi- nion respecting its mode of action should have existed among physiologists and physicians. By some it has been deemed sedative, by others stimu- lant, by some debilitating, by others tonic. The truth is, that its operation varies with the circum- stances of the case. Regarded abstractedly as a medium of communicating cold, there can be no doubt that the cold bath must be considered as de- bilitating in the highest degree, inasmuch as its continued application will eventually produce death, from exhaustion of the nervous energy and 268 BATHING. derangement of functions essential to life. But when we speak of the cold bath medically, we do not regard its absolute effects, but its effects when applied in a particular manner, and regulated ac- cording to certain views. Like many other reme- dies, it may be debilitating to the destruction of life in one dose, and yet salutary and tonic in an- other. Accordingly, when used in the proper case, at the proper time, and in the proper manner, the cold bath is unquestionably one of the most powerful tonics in the whole range of the Materia Medica, and it is chiefly as such that it is used in medicine. § 2. Of the special effects of the cold hath as a medical agent; and of the mode of ensuring them. The cold bath is employed, in individual cases, chiefly with the view of producing one of the three following effects : — 1. the shock on the nervous system, independently of the accompany- ing refrigeration or subsequent re-action ; 2. the refrigeration, independently of the nervous shock, or vascular re-action ; and, 3. the re-action inde- pendently of the shock or refrigeration. The two first of these objects are of inferior practical im- portance ; the last comprehends nearly the whole doctrine of cold bathing. I. The nervous impression, or shock.—When the cold bath is employed with the view of pro- ducing the shock, properly so called, or primary nervous impression, and if it is desired that this should be great, the water is used at a low tem- perature, and the application of it is sudden, forcible, and brief. To this end the patient is either plunged suddenly into the water and in- stantly withdrawn, or the water is dashed over him in the form of affusion. A familiar example of this use of the cold bath is the sprinkling the face and breast of a person disposed to swoon. On the same principle a more copious affusion is used in certain convulsive diseases, more espe- cially those of an hysteric or purely nervous kind. In such cases the application is often extremely serviceable. It has likewise been used in con- vulsive affections of a more permanent kind, as in chorea, tetanus, and epilepsy, but with less bene- ficial effect in general, and not always with safety. The same practice was formerly employed in mania; the mode of administering it being, in this case, to cause the unhappy maniacs to tumble unawares into a deep plunge-bath or pond. With a similar view the cold bath, chiefly in the form of a copious and forcible affusion, was much em- ployed in fever, in the hope of breaking the train of morbid actions in which fever was imagined to consist. In all these cases, although the object is to ob- tain the primary nervous shock through the sud- den impression made on sensation; yet as there necessarily co-exist with this, refrigeration of the surface and repulsion of fluids to the internal parts, the secondary effect, termed re-action, is frequently an inevitable result of this application of the bath. In the cases, therefore, in which re- action is likely to prove injurious, the remedy should not be used, as it is hardly possible to avoid its occurrence ; or when used, the applica- tion should be extremely short, and the body should be dried immediately. Before making trial, in any case, of a remedy so powerful, care will, of course, be taken to ascertain, as far as this is practicable, the powers of the system to sustain the shock. II. Refrigeration. When the object is to ob- tain the refrigeratory action of the cold bath, with as little as possible of the nervous shock or vas- cular re-action, it must be applied in the way least likely to produce the two last. We shall see presently that the degree of re-action is, cxteris paribus, proportioned to the degree of cold, if this is only temporarily applied ; we have just seen that the nervous impression is proportioned to the suddenness and vehemence of the application of the water, and also to its coldness; if, then, we wish to produce the refrigeratory effect alone, we must neither apply the water of a low temperature, | nor suddenly, nor forcibly. The only cases in which refrigeration is re- quired as a remedy, are those in which the animal temperature is elevated above the natural standard; and this happens only in febrile diseases. In symptomatic fevers, the consequence of local in- flammation of the viscera, this remedy is rarely applicable; being usually, when so employed, productive of an aggravation of the disease. In the class of fevers termed idiopathic, as in the common continued fever of this country, or ty- phus, cold water has been extensively used, and often with benefit. In the preceding paragraph we have already noticed one mode in which this remedy has been applied, not however with the view of refrigerating the surface, but of suddenly cutting short the disease. When this latter object is not attained, the result has commonly been an increase of the febrile heat and vascular excite- ment. To ensure refrigeration in this and other cases, the water should be applied at first only a little below the temperature of the skin, its heat being insensibly and gradually reduced, but never below that of tepid, or at most cool. The gen- tlest mode of applying it is the best, as with a soft sponge ; and the process should be persevered in without interruption until the desired effect is produced. The non-interruption of the applica- tion is the more essential in proportion as its tem- perature is low. In local affections of an inflam- matory kind, in which very cold lotions are used as a refrigerant, as in cerebral inflammations and in phlegmon, the result is frequently different from what is intended, from neglect of the precaution just mentioned. The renewed application of the cold fluid, after a temporary suspension, frequently gives rise to a series of re-actions in the part, which are calculated much more to aggravate than to relieve the disease. In such cases, if the lotion is very cold, its application ought to be un- interrupted until the intended effect is produced. If the water is of a temperature little below that of the body, the interruption of its use will have no further injurious effect than the subtraction of the amount of good which its continued applica- tion is calculated to produce. III. Re-action, or glow---The cold bath may be used, in the third place, with the view of pro- ducing its secondary effects—re-action. As this is by far the most important end for which it is employed, and as, indeed, almost the whole prac- tical doctrines relating to cold bathing are involved BATHING. in the consideration of this subject, we shall devote a considerable portion of the remainder of this part of our article to an examination of the circum- stances which obstruct or favour its production. 1. The degree of re-action is, in general, cxteris paribus, proportioned to the coldness of the water. A very cold bath is followed by a speedy and powerful re-action ; a cool bath by a slighter re- action, and after a longer interval; while a bath approaching the limits of tepid produces scarcely any re-action. 2. In general the re-action is proportioned, cx- teris paribus, to the suddenness and also to the force with which the body is brought in contact with the bath. An instantaneous immersion pro- duces a greater re-action than a gradual immer- sion ; and a plunge from some height produces a greater re-action than a gentle dip, however ra- pidly performed. In like manner, water falling on the body from some height has a much greater effect than simple ablution with water of the same temperature. 3. Within certain limits, that is, short of the period at which healthy re-action ceases to be produced, the re-action is, in general, proportioned to the period of stay in the bath,—in other words, to the degree of refrigeration. 4. The re-action is commonly proportioned to the vigour of the circulation in general, and more particularly to that on the surface; it is likewise proportioned to the warmth of the skin and ex- tremities previously to immersion. It is, there- fore, a constant rule that persons with a feeble circulation and cold extremities must endeavour to invigorate the circulation, and increase their temperature previously to using the cold bath. To ensure the proper degree of power, it is even necessary, in some cases, to administer a warm beverage, or to take a glass of wine before enter- ing the water ; and were it always convenient, it would often be beneficial, in cases of this kind, to go into the warm bath for a few minutes before immersion in the cold. 5. Re-action is greater, cxteris paribus, if muscular motion is exerted in the bath, than if the patient remains in a state of repose. Swim- ming is therefore more tonic than simple immer- sion, and the large open bath admitting of motion more tonic than the common small bath. The increase of re-action from motion is partly owing to this producing a greater feeling of cold, by oc- casioning a quicker change of the particles in contact with the surface ; but principally by the increased excitement resulting from muscular exertion. In the case of swimming, as in all others, it is always to be understood, when spoken of in relation to its power of increasing re-action, that the period of stay in the water is not pro- longed beyond that suited for the production of all degrees of re-action. 6. Whatever tends to prevent the temperature of the surface from falling below the proper degree, or directly stimulates the skin, or excites the action of the heart, will proportionally in- crease the power of re-action. On these grounds, the speedy drying of the body on leaving the bath, strong friction of the surface or the applica- tion of heat to it the drinking of warm fluids, or active bodily exercise, will ensure or increase re- action ; while the omission of these measures, or measures of an opposite kind, will produce op- posite effects. § 3. Of the practical administration of the cold bath, and more particularly of the salt-water bath. Although it is certain that the most important of the effects produced by baths depend on their temperature, and on other circumstances having no relation to their chemical constitution, it will not be doubted by any practitioner of experience, who has had sufficient opportunities of comparing the effects of the bath of simple water with those of mineral waters or of the sea, that the chemical composition of the materials used in bathing is a matter of considerable importance. Without at all entering here upon the question of the powers of absorption possessed by the skin, whether of water simply applied to it or of substances dis- solved in water, experience has satisfactorily proved that the effects of immersion in pure water, and in water containing salts in solution, are different. Sea-water and mineral waters, par- ticularly such as contain sea-salt or iron in solu- tion, are more tonic, stimulant, and bracing than simple water, and when used as a cold bath are productive of a greater re-action than the latter. When, therefore, the object is to produce re-action, and to brace the system, (and this is the object in a vast majority of the cases in which the cold bath is used,) sea-water is always to be preferred to fresh. If this cannot be procured, the water ought, when practicable, to be rendered artificially saline by the solution in it of common salt. For these reasons, and because in the greater number of cases in which cold bathing is proper the summer temperature of the sea is exactly that most suitable,—and, moreover, because this is the form of the cold bath in most general use in this country,—we shall, in the present section, direct our attention particularly to sea-bathing. 1. The period of the year best adapted for sea- bathing is, of course, the summer and autumn, at which seasons the temperature of the sea on our shores varies from 55° to 70°. Bathing in the open sea may, however, be prolonged beyond the autumnal months, and even through the whole winter in particular cases. It will scarcely ever be proper to commence sea-bathing in the latter season ; but many persons who have regularly used it in the summer and autumn may continue it through the severer season with great advan- tage. Such a recommendation presupposes the possession of a vigorous constitution, or, at least, great powers of re-action in the patient. 2. The time of the day for bathing in the open sea must depend, in many places, on the state of the tide. A slight deviation may be allowed on this account; but the particular time best adapted to the invalid must not yield to reasons of mere convenience. By the majority of persons for whom the cold bath is prescribed, either as a measure of hygeiene or as a remedy, the best time for using it will be about noon; that is, two or three hours after breakfast. At this time we may presume that the system is sufficiently recruited by the assimilation of the morning's meal; and we may yet farther be enabled to ensure re-action by such previous exercise as may be deemed pro- 270 BATHING. per. In very hot and calm weather, the sun is, however, often too powerful at noon for delicate persons, more particularly on those parts of our southern shores which are sheltered by high cliffs. In these cases an earlier hour must be chosen, or bathing in the open sea must be given up. When the constitution is vigorous, and the temperature of the surface is uniformly high, and when the patient rises from his bed refreshed and active, the bath may be taken early in the morn- ing, before breakfast This is, in general, the best time for using the cold shower-bath; and the reason why it is found to suit better at this hour than the sea-bath, probably is, that the shower-bath is taken immediately on rising, while the surface still retains all the warmth of the bed. If one could plunge into the sea as easily, and before the surface is at all chilled by dressing, &c, there is no doubt that the practice would suit very well with many with whom it is found to disa- gree. In using the open sea in summer, it may be of some consequence to recollect that the tempera- ture of the water may be very different at different times, according to the circumstances of the local- ity, the hour of the day, and the period of high water. If the shore consists of level sand or shingle, the tide which flows in the afternoon, over a large expanse of surface heated by the noon- day sun, during the period of ebb, will often be a good many degrees higher than the morning tide in the same place.* 3. In using exercise previously to the bath, with the view of rendering the circulation more vigorous, according to the principles formerly stated, the invalid must be careful not to induce fatigue or much perspiration. A slight moisture on the skin (which, however, should be wiped off previously to entering the bath,) forms no objec- tion to its use, provided the surface still continues warm and the circulation vigorous; but if the body has been for some time losing its heat by copious perspiration, and the general powers of the system have been lowered by fatigue, the cold- bath cannot be used without danger, however warm the surface still may be. 4. The mode of entering the bath, the length of time the patient remains in it, and other par- ticulars, must be regulated according to circum- stances. From what was formerly stated, the propriety of entering the bath suddenly will be seen, and likewise the necessity of leaving it while there still remains sufficient power of reac- tion. The advice commonly given to a patient to take at first only one or two dips to ascertain the power of re-action possessed by him, and gradu- ally to prolong the period of stay in the water, is judicious. From five to ten minutes may be said to be a medium period for staying in. Moving the body and limbs while in the water is highly ad- visable, and, of course, the exercise of swimming, * The following memorandum shows the temperature of the sea at Bognor, on the coast of Sussex, in the sum- mer and autumn of the year 1831. On the 4th July, at mid-day, the temperature of the atmosphere being 72°, the sea was 60°. July 12, 7 a. m. Atmosph. 630, Sea 66° Aug. 3, 8 p. m. Atmosph. 65°, Sea 71°. Aug. 11. 1 p. m. Atmosph. 70°, Sea 71°. Sept. 5, 8 a. m. Atmosph. 640, Sea 650. Oct. 29,11a.m. Atmosph. 60", Sea 34°. if the patient possesses the requisite power and skill. The body should lie speedily dried, and hastily but well rubbed with a somewhat coarse towel, and the clothes put on without any unne- cessary delay. In ordinary cases no further pre- caution will be necessary to ensure the requisite degTee of reaction; but in very feeble subjects the measures formerly mentioned in reference to such cases, must be put in practice. 5. The cold bath may be repeated daily or every other day, or twice a week, according to the nature of the case, the effects of the remedy, and the state of the weather. It may be continued indefinitely and uninterruptedly, or it may be taken for a short time, omitted for a space, and then resumed. Where it is found to agree with the patient, it ought to be continued at least one month, and may be very beneficially extended to three. 6. A common and often a most injurious error in the practice of sea-bathing is, that the patient remains so long in the water that the animal heat is lowered below the proper degree. This is an error, however, more commonly committed by persons using the bath as a luxury, than by invalids. In boys of a feeble constitution or strumous habit we are convinced that great mischief is often pro- duced in this Way, when it is least expected. The principle on which such results are explained has been ably illustrated by Dr. Edwards, in his ex- cellent work On the Influence of Physical Agents on Life. It was ascertained by him, in the course of his experiments on living animals, that the temporary elevation or depression of the animal temperature, above or below the natural standard, not merely added to or subducted from the system the amount of caloric necessary to produce the effect indicated by the thermometer at the time, but modified, for some time afterwards, the activity of the calorific process itself. Animals whose temperature had been raised by artificial heat, were invariably found, on the withdrawal of this, to continue for some time to generate more heat in the same period, than before the experiment; and those whose temperature had been lowered, to generate less. Although Dr. Edwards's experi- ments were confined to the inferior animals, both analogical reasoning and observation leave no doubt that the principle is equally applicable to the human subject Every one must have had occasion to observe, and most people to experience in their own persons, the effects of a severe chill being felt long after the usual temperature has been restored. Subsequently to long exposure to cold, as in a carriage or church, when the clothing is insufficient, or when cold bathing has been improperly prolonged, a sense of chilliness often remains for days, although the body has been repeatedly and thoroughly warmed in the mean- time. We have known such a state continue for two or three weeks, the individual daily expecting the invasion of some formal disease, and yet none such occurring. The corollary from these premises is, that when the cold-bath is employed with the view of invigo- rating the system, it should never be so prolonged as materially to lower the animal temperature. In such cases the re-action will either be imperfect or it will be succeeded by a sense of chilliness. BATHING. 271 In order to obtain the full degree of salutary re-ac- tion, and at the same time to avoid the risk of subsequent chilliness, immersion in the cold-bath should cease just before the animal temperature is sensibly diminished ; and it may be deemed, for all practical purposes, a sufficient test that this point has not been passed, as long as the primary glow or reaction is felt to continue. § 4. Of the Temperate Bath (75° to 85°). The effects of this bath on the system are pre- cisely the same in kind as those of the cold-bath, but they are much less in degree. This bath, therefore, is applicable in a different class of cases, and it is also applicable in the same cases in which the cold or cool bath may be of use, but cannot be applied without some hazard. The Buxton water, which is of the temperature of 82°, is the best natural example of this class of baths. The shock produced by water at this temperature is small, and the re-action proportionally slight. As this bath may, therefore, be safely prescribed in cases where danger might be apprehended either from the too powerful shock on the nervous system, or the too great and sudden retropulsion of fluids on the internal organs, it will, for the same reason, be found much less efficacious in the cases in which the principal benefit results from a powerful re- action. It will also be frequently preferable in the case of delicate persons, and in persons of peculiar sensitiveness either of the whole system or of the skin only, in whom the shock of the very cold bath, or even the cool bath, cannot be borne; although if it could be borne, its effect in repelling the fluids could be productive of no evil. In such cases, and in others also of a somewhat different kind, a bath of this temperature will often be proper as a preparation for the use of the bath at a much lower temperature. It is, indeed, a question often raised, whether the patient should at once commence with the bath of the full degree of coldness intended, or should at first use one of a higher temperature and gradually lower it For instance, should a patient for whom the cool or cold bath is prescribed, begin at once with it, or previously use that which we are now considering ? This point can only be fixed in individual cases. Generally speaking, if there is any doubt of the system being able to bear the shock of the cold bath, the temperate should be raised, and more particularly in the case of delicate persons and women and children, and in persons who have a dread of the effects of the bath. It is always to be recollected, however, that if our object is to corroborate the system by produc- ing re-action, the lower temperature is decidedly best, if it can be borne. And we are of opinion that among the vast number of cases in which the cold or cool bath is indicated, very few will be found in which it will not be borne at once. All that is necessary is, by proper management before and after the bath, and by making the immersion extremely brief, to ensure the salutary degree of re-action. § 5. Of the different Forms of the Cold Bath, and their particular Effects. 1. Large and small baths — open and close baths. The observations heretofore made may be considered as applying generally to every form of bath by immersion, whether the water is in the open sea, rivers, ponds, &c, or confined under a roof in large or small baths. It must not, how- ever, be imagined that it is a matter of indifference to the patient under what circumstances the bath is administered. It may be stated in general terms that bathing in the open air is more advan- tageous than bathing under cover, and that a large bath is preferable to a small one. It is scarcely necessary to observe that when a tonic effect from the cold bath is the object, the open air, more par- ticularly of the sea, will be much more bracing than that of a confined apartment The size of the bath is of still greater consequence. In the common domestic bath, the patient can scarcely have the advantage of a complete and sudden immersion ; and all effective motion, while in the water, is completely precluded. The importance of this deficiency will be understood from what was formerly stated on the subject of re-action: in the small bath, the degree of refrigeration is often not sufficiently balanced by a proportionate degree of this salutary process. For these and other reasons, the large baths at Matlock, Buxton, &c, are decidedly preferable to the small baths at the same places. Of all the substitutes for the open sea which we have seen, the swimming bath lately erected at Brighton is by far the be6t From its great extent and airiness, and the constant re- newal of the water, this bath certainly possesses many of the advantages of the open sea, and it has one superiority, that, namely, of being accessible in every kind of weather and at any time of the day.* 2. The shower-bath. — The form and general character of the shower-bath are too well known to require description. Its effects are, on the whole, similar to those of the plunge-bath of the same degree of temperature : but there are some differences between them which deserve the notice of the practitioner. The immediate shock from the shower-bath is, in general, felt to be greater than that from simple immersion ; more particularly if the quantity of water is great, its temperature low, and the fall considerable. On the other hand, owing to the absence of permanent compression of the surface by a dense medium, and perhaps, also, owing to the access of air to the skin in the case of the shower-bath, the anhelation and precordial distress are generally less in degree and certainly less per- manent than in the plunge-bath. From these and various other circumstances, individuals constantly present themselves to the practitioner who will bear the one form of bath and not the other, or who will be more benefited by the one than the other. In certain affections of the head, and in persons predisposed to such affections, the shower-bath possesses a very decided advantage over the plunge- bath, inasmuch as the shock and refrigeration are applied directly and in the first place to the head. And in these and many other cases also, it is a great advantage possessed by this bath, that the feet may be immersed in hot water during the process. This not only tends to prevent too great * The swimming bath at Brighton is 53 feet in diame- ter ; its depth from 3 feet 6 inches on one side to 5 feet 6 inches on the other. 272 BATHING. a repulsion of the fluids upon the internal organs in cases where this is to be apprehended, but in feeble and sensitive persons it tends at once to lessen the shock and to increase the re-action. It is an important advantage possessed by the shower-bath, when properly constructed, that it can be increased or diminished in force, suspended, renewed, shortened, or prolonged, according to the . feelings of the patient* The small quantity of water necessary to prepare a bath of this kind is another great advantage, as giving facility for having it at any degree of heat required. 3. Affusion, aspersion, ablution.—These may be employed either as general or local baths. Water thrown over the naked body from a vessel is a rude form of the shower-bath, and has similar effects. By ablution, we commonly understand the process of applying water to the surface by means of a sponge or towel. When general, it differs only from the shower-bath in being attended by a lesser shock, and consequently a feebler re- action. It is much more frequently used as a par- tial bath, more particularly to the head and trunk of the body, in which form we consider it as one of the most valuable applications both hygeienic and therapeutic. The daily ablution of the chest with cold water, containing vinegar or salt in so- lution, is one of the most effective tonics in a numerous class of diseases, and the easiest and surest remedy of that almost general and, we fear, increasing disease, a proclivity to catch cold. (See the article Asthma.) This form of bath is always to be used, by the delicate, in the morning, imme- diately on getting up, while the body still retains all the warmth of the bed, unless, indeed, there is perspiration present at this time. The employment of cold ablution as a remedy in fever was formerly noticed. In this case, pure water should be used ; in most other cases, salt water, or water rendered artificially saline, is pre- ferable. 4. The douse (dash, or douche).—This form of bath is well known by its foreign name. It is of sufficient value to deserve an English appella- tion, and we venture to revive an old one, which has at least the negative advantage of being less discordant to our orthography and pronunciation than the French term.-f- The douse consists of a small stream of water directed with considerable force from a tube upon some particular part of the body. It varies in its power according to the dia- meter of the stream, the temperature of the water, and the force with which it is projected on the body. It is an agent of great power; but it is more employed in the domain of surgery than medicine. This is, perhaps, the most effectual of all refrigerants, owing to the incessant and rapid change of the particles of the fluid applied to the * A shower-bath should be so constructed as to contain a much greater quantity of water than is usually thought necessary, and to permit the shower to be suspended and renewed at the will of the bather. One of the most con- venient forms is that which is erected over the common domestic warm bath, and which permits the patient to escape from under the stream, and to return to it at pleasure. The materials for enclosing the shower-bath ought lo be of wood, as cloth or canvass, whether painted or not, retains moisture, and proves thereby injurious by occasioning dampness. t The douse, (pronounced like house,) from the old neu- ter verb, to douse, to fall suddenly into the water. part, and also to the compression on the capillaries produced by the mechanical impulse of the stream. A homely form of the douse is the placing the affected part under the stream from the nozzle of a pump, or the spout of a tea-kettle. The chief instances of a strictly medical kind in which this form of bath is used, are to the head in cerebral diseases, and to the loins in uterine affections. In inflammatory affections of the brain, whether idio- pathic or originating in fever, it is a most potent remedy. It is also in frequent use, in some parts of the continent, in mania. In all these cases it requires to be used with discrimination and great circumspection, as it is capable of producing the most powerful effects. 5. The hip-bath, foot-bath, #c.—There is no limit to the number of partial baths but the num- ber of parts of the body to which water can be locally applied. The most important are the two just named. They are both very valuable reme- dies, and their administration is well understood. The former is principally used in diseases of the pelvic viscera ; the latter chiefly as a measure of hygeiene. Children ought to be accustomed to the daily use of the cold foot-bath, as nothing tends more to prevent chilblains—a disease, how- ever apparently slight, of really serious conse- quence in delicate habits. § 6. Of the diseases in which the cold bath is employed; and the contra-in- dications to its use. The applications of the cold bath, both as a measure of hygeiene and as a curative agent, are numerous and important. It is, indeed, one of the most valuable remedies we possess. Like all valuable and powerful remedies, however, its em- ployment requires great caution and discrimina- tion, first, as to whether it should be used at all; and, secondly, as to the form and mode of using it It must be confessed that in a vast number of cases no such discrimination is practised ; and it will not be doubted by any physician resident in the vicinity of the sea, that in the case of no other remedy are greater mistakes committed and greater mischief produced than in the use of the cold bath. It is impossible, within the limits of the present article, to do more than give an outline of the numerous cases in which the cold bath is beneficial. This, however, is of the less conse- quence, as the practitioner who is acquainted with the mode of action of this remedy, and the gene- ral principles which ought to regulate its employ- ment, (and we have endeavoured to explain these in the preceding pages,) will have little difficulty in applying it to individual cases. Before entering upon the consideration of the diseases in which this remedy is proper, it will be well to give a brief statement of the particular conditions of the system, whether morbid or not, which either entirely forbid its use, or render great caution necessary in employing it 1. The cold bath is less applicable in infancy and old age than in youth and middle life. 2. It is not admissible during the menstrual period, and only with great caution during preg- nancy. 3. It is inadmissible in great plethora; in cases where there exists a predisposition or tendency to BATHING. 273 active hemorrhage, to local congestions in the more important viscera, &c.; consequently in apoplectic subjects, in a tendency to haemoptysis, &c. 4. It is improper in persons affected with dis- ease of the heart, particularly with dilatation or valvular obstruction j and it must be used with great caution in those who, without any formal disease, have naturally a thin and feeble heart. This is often the case in strumous and phthisical habits. 5. It is generally inadmissible in indurations, obstructions, or chronic inflammations of the in- ternal parts of the body, more particularly of the principal viscera; likewise in all acute inflamma- tions of the same parts; and also in chronic inflammations of the mucous membranes of the bronchi and intestinal canal, except when these last are very slight. 6. It is improper in loaded states of the bowels, more particularly if these are combined with a gorged state of the venous system of the abdomen. 7. It is either inadmissible, or only to be used with great caution, in most cutaneous diseases ; particularly such as are apt, when suddenly re- moved, to be followed by internal affections. 8. It is inadmissible in great general debility, and where there does not exist sufficient power of re-action, more especially if there exists an habitually cold state of the surface. In cases of this kind, however, the cold bath may be often advantageously employed after the previous use of the warm water or vapour bath, provided the debility is not the result of some local organic disease. One of the most important class of cases, short of formal disease, in which the cold bath is bene- ficial, consists of the various forms of general debility which show themselves in childhood and youth, either as congenital constitutional peculi- arities, or as the consequences of previous disease. Of the first kind, the strumous habit constitutes the most important example. In cases of this kind, when properly selected, the cold sea-bath and a residence by the sea-side are frequently of very singular benefit. Every thing, however, depends on the judicious selection of the cases, and on the proper administration of the remedy ; since quite as much injury as benefit may result in this class of cases without the greatest care. In children of a strumous habit we have at the same time, in general, a feeble heart, and a very sensitive surface. Great caution is, therefore, necessary, in first administering the bath, lest the shock be too powerful for the energies of the sys- tem, and be not followed by the necessary degree of re-action. Every measure formerly mentioned as proper to ensure this result must be employed, as otherwise the bathing will be highly injurious. In most cases it will be found sufficient to take care that the circulation on the surface is as vigorous as possible previous to immersion; to make the immersion sudden and complete, and, at first, merely momentary, and to follow it up by strong general friction with flannels. In more deUcate subjects it may be necessary to begin with the tepid or temperate bath, or to take some of the additional precautions formerly noticed. It is j a matter of great consequence in bathing children, , Vol. I. — 35 that they should not be terrified by the immersion, and every precaution should be taken to prevent this. A course of baths, gradually reduced from a high to a low temperature, is beneficial in this point of view, even if it were not often so likewise by improving the condition of the skin, and ren- dering it more susceptible of re-action. It is to be here understood that it is to the strumous habit, and not to the diseases of scrofulous persons, that the foregoing observations are intended to apply; as we are well convinced that there are few such diseases in which the cold bath is not injurious. Great care must therefore be taken by the practi- tioner, before prescribing this measure, to ascertain that there exists no local disease of consequence. We do not consider slight swelling of the external glands as a positive contra-indication of the cold bath, provided the internal organs are sound; but such appearances are always suspicious, and im- pose greater caution in the use of the remedy than if they did not exist. When, in strumous habits, the system is free from visceral disease, and sufficient energy exists to produce strong re-action, the frequent repetition of this exciting and tonic process may eventually establish a permanent degree of increased activity and power throughout the whole capillary sys- tem, with an habitual development of a higher degree of temperature on the surface. Such re- sults may be considered equivalent to a change in the very temperament of the individual; and it is certain that they are occasionally attained by the use of the cold bath, aided by suitable regimen. In children of a feeble and delicate habit, the result of previous disease, perhaps still greater caution is requisite in prescribing the bath, as such states of general debility frequently depend on organic affections of the viscera. In this last case, the remedy is altogether improper, and can- not be administered without danger. The same remark is equally applicable to persons in more advanced life. We may add, as a general obser- vation, that there is scarcely a more common or more injurious practical error, than this of assum- ing debility to be general, when it is the result of some local affection. In all cases of this kind, at whatever period of life, cold bathing is seldom beneficial, and very generally injurious. Here, as in most cases, it is to be viewed in the same light as other tonics, which may be stated as ge- nerally contra-indicated in what may be termed symptomatic debility. In place of being strength- ened, such persons are certainly debilitated by the treatment, and great risk is incurred, not only of increasing the primary disease, but of pro- ducing others. It is in such cases that we observe the occurrence of bilious and febrile attacks, headachs, and other disorders, so frequently no- ticed as results of indiscriminate sea-bathing. Permanent headachs have been produced under such circumstances. In cases of a debilitated and relaxed habit, free from visceral disease, from whatever cause arising, the cold bath may be considered as useful, if suf- ficient power of re-action exist in the system. When the skin is relaxed and flabby, and there is a great tendency to warm perspiration on slight exertion, or to cold clammy perspiration in bed, 274 BATHING. the salt bath is especially indicated. In no class of persons is this measure more beneficial than in those who inhabit a low, relaxed, damp cli- mate, in whom debility and nervousness in various forms, and relaxation of the skin and mucous membranes, are frequent and conspicuous ail- ments. When combined with a more bracing climate, and dry pure air, the benefit from this measure is often most speedy and remarkable. For persons of this class, no place on the south- ern coast affords such advantages as Brighton, and some other places in its vicinity, where the high, airy downs come close to the sea brink. There is one case of debility frequently met with in practice, which requires great caution in prescribing the cold bath, and where frequent mistakes are committed, for want of due discrimi- nation : we allude to that state of debility which so often precedes the development of tubercles in the lungs, and which has been so well described by Dr. Clark, under the name of tubercular ca- chexy. (The Influence of Climate, &c. Lond. 1830.) If tubercles already exist in such cases, (and we know that they often do so without any external or local symptoms of their presence,) cold bathing will almost always be found to disa- gree, and will tend to accelerate the fatal disorder of the lungs. If only the predisposition exists, and the system still retains sufficient power of re- action, a cautious use of the cold bath may prove extremely beneficial; but in no case is more care requisite to ensure reaction, without which the measure cannot fail to be highly injurious. As a preventive of the numerous diseases pro- duced by cold, or rather by the variations of tem- perature, the cold bath, in one or other of its forms, excels all other measures. In the nume- rous family of catarrhal disorders, it is almost the only preventive of value; and frequently it is here of extreme value. It obviously acts in vari- ous ways in warding off these diseases. In the first place, it acts as a tonic to the whole system, thereby rendering it less easily affected by delete- rious influences from without. Secondly, it strengthens, in a peculiar manner, the skin and the mucous membranes of the air passages, on which parts the morbific impressions producing catarrh are generally made. In the third place, by accustoming the surface to a frequent change of temperature, it renders it less liable to suffer from those which are unavoidable, and which are known to be the common causes of colds. The same observations apply, in a great measure, to rheumatism, chilblains, and other diseases pro- duced by the same class of causes. When used with the view of preventing these diseases, the bath, in some form, ought to be pro- longed through the different seasons. In the summer sea-bathing will be best, and, afterwards, the shower-bath, or ablution. In most cases it will be found sufficient to employ the latter par- tially to the chest and trunk, after the weather has become cold; and it should be continued through the whole winter. The cold bath may be said to be applicable to the whole class of nervous diseases, properly so called,—that is, diseases which manifest them- selves chiefly by morbid mobility or excitability of the nervous function, and irregular action of the muscular system,—provided there exists no considerable physical change or obstruction, as it is commonly called, in any important viscus, and provided the first impression of the remedy is not found too powerful, cither as an exciting or de- pressing agent. It is, however, more generally useful in those slighter, anomalous, nervous affec- tions, so constantly met with in practice and under such varieties of form, than in the more formal and well-marked diseases which are alone treated of in our systems of medicine; although it is a valuable remedy in many of the latter class, when none of the contra-indications above noticed exist against its use, and when it is applied in the mode and form best suited to the individual case. Of this kind are chorea, hysteria, some cases of epi- lepsy, loss or depravation of certain functions, as loss of voice, smell, taste, &c; certain forms of hypochondriasis ; local paralytic affections uncon- nected with cerebral disease, such as loss of power in the sphincters of the bladder or anus; certain cases of palsy of long standing, in which all active cerebral affection has been removed, &c. In some of these cases the remedy is frequently only of doubtful utility, and must therefore be administered with great caution. The chief cir- cumstances which contra-indicate its employment in such cases, are the existence of organic disease in the brain or spinal marrow, or a disposition to cerebral congestion. In all such cases, and wher- ever any doubt exists as to the propriety of the remedy, the shower-bath is the preferable form; and this is the only form which should be used in any case of epilepsy. The cold bath is beneficial in many chronic affections of the mucous membranes attended with discharges, such as Ieucorrhoea, gonorrhoea, &c; also in certain cases of chronic catarrh, attended with little or no inflammation of the bronchial membrane, particularly in the dry catarrh, and in those forms which seem to depend rather on a relaxed than an irritated state of the bronchial membrane. It is occasionally beneficial in cases of passive hemorrhage, particularly epistaxis and menorrha- gia. It is sometimes usefully employed in cases of nervous or functional dyspepsia, unaccompanied with inflammation of the gastro-intestinal mem- brane, more particularly after a course of warm bathing. Its employment in mania was formerly noticed. For the use of the cold bath in febrile diseases, we refer to the article Feveh. We would only here repeat, what was said in a former section, that the tepid or cool ablution is the form most adapted to such cases. The cold bath is useful in certain cases of ame- norrhoea, particularly where there exists neither a very plethoric state of the habit, nor yet chlorotic debility. In chlorosis, properly so called, cold bathing is rarely admissible. In no disease is the cold bath more beneficial than in the intervals of asthma, when the system is otherwise in a proper state for the remedy. In this case its principal action is, no doubt, as a pre- ventive of catarrh or cold, which is by far the most frequent exciting cause of the disease. It also operates by giving tone to the nervous system, BATHING. 275 and rendering it the less susceptible of morbid impressions. (See Asthma.) On the same prin- ciples it is beneficial in the latter stages of hooping- cough. It is likewise useful in the intervals of ague, when the disease exists in a simple state, uncomplicated with any visceral affection. OF WABM BATHING. § 1. Of the phenomena and operation of Warm Baths in general. The only forms of the warm bath which it is our intention to notice in the present article, are, the water, vapour, and air bath. As these are respectively productive of effects sufficiently differ- ent to entitle them to be regarded as distinct medi- cal agents, we shall treat of them separately ; but as they all agree in some important particulars, it will save repetition to notice these, in the first place, under one general head. This we shall do in the present section. The immediate action of the warm bath on the system is, like the sensations excited by it, in many respects the reverse of that of the cold bath. In the latter, nature seems to encounter a hostile power, which she must overcome before she can make it minister to her comfort; the pleasurable feelings thence resulting being derived rather from the operations of the system itself, than from any impressions communicated to it from without. The warm bath, on the contrary, is directly grati- fying to the feelings, and seems at once acknow- ledged as a power friendly to life. In the new medium, the surface and extreme parts seem to partake of that animating sense of heat which is, in general, confined to the trunk and central parts of the body. The following are some of the principal modes in which the warm bath affects the animal body. 1. It acts directly, and in a way altogether in- comprehensible to us, on the nervous system; partly, no doubt, by modifying sensation, but also by producing effects which seem unconnected with any such modification. Its effects vary consider- ably with the medium, but more particularly with the degree of heat communicated. When the temperature of the bath is confined within certain limits,—as for instance, when the water bath is of the temperature of 95°, 96°, or 97°, the whole nervous system is, in general, soothed, the feelings are gratified, and a gentle languor steals over the mind. Slight degrees of local irritation, pain, or spasm, that may be present, are frequently re- moved, and even, in some cases, great general irri- tability of the system is effectually subdued, at least during the continuance of the bath. At a temperature somewhat higher than this, the bodily and mental feelings are still gratified, but a very brief continuance of the remedy produces excite- ment in place of tranquillity. If the heat is con- siderably greater, the feelings are painfully excited, and the temporary stimulus is followed by a pro- portionate degree of exhaustion. 2. The warm bath influences the system by elevating the temperature either of the whole body or a part of it If the parts which come in im- mediate contact with the heating medium are be- low the general temperature of the body, they will be gradually raised to this temperature, if the bath is continued. If the heating medium is of a temperature greatly above that of the body, it will raise the superficial parts, and even the whole mass of blood, above their ordinary degree of heat. The extent of this elevation, however, as is well known, is confined within very narrow limits by that wonderful power of the living body which regulates its temperature, in a very considerable degree, independently of all external influence. While life remains, we can neither greatly elevate nor greatly depress the general temperature of the body by any degree of heat or cold applied to it. This conservative power, however, does not con- fer a complete immunity from the operation of the ordinary laws that regulate the distribution of caloric in inanimate matter. A great and long continued degree of cold sensibly depresses the animal temperature even of warm-blooded ani- mals, at least in the external parts; and a great and long continued heat raises it in like manner. The degree of heat which can be borne by the living body, as communicated by different media, varies extremely. The variation depends upon several circumstances in the nature of the heating medium, more particularly on its density, its capa- city for caloric, its conducting power, the degree of fixedness or mobility of its particles, &c. Thus, the heating power of dry air is much less than that of moist air at the same temperature ; this is much less than air loaded with vesicular vapour, as in the instance of the vapour bath; and this, in its turn, is greatly less than the common fluid or water bath. 3. The warm bath modifies very considerably the functions of the skin, as an exhalent and ab- sorbent organ. We must refer to the writers on physiology, and more especially to the work of Dr. Edwards, (De l'lnfluence des Agens Phy- siques sur la Vie. Paris, 1824,) for the full expo- sition of this important effect of the bath. We can only, in this place, refer to the principal points which seem to be established. a. In the state of health, the skin appears both to exhale and to absorb fluids in the water bath. The relative amount of the two processes appears to vary considerably with the temperature. At very low temperatures, and up to about 50° Fahr., absorption by the skin exceeds transudation. From this point to about 70°, the two processes would seem to be pretty equally balanced. Above this | degree the transudation exceeds absorption, and the excess progressively increases with the tem- perature. b. The temperature of the bath, or rather the degree of heat communicated to the body, being the same, and other things being equal, the degree of absorption is proportioned to the density of the fluid in which the body is immersed. Much more fluid is, therefore, absorbed in the water bath than in the vapour bath. It is not ascertained that the [ amount of exhalation is in the inverse ratio of the density of the fluid ; on the contrary, there I are strong grounds for believing that this is not the case : it is, however, ascertained that in the vapour bath the transudation exceeds the absorp- tion. c. In the warm air-bath the difference between the two processes is at the maximum, since the transudation is often extremely copious, while ab- 276 BATHING. sorption is almost of necessity null from the ab- sence of the material to be absorbed. There is reason to believe that the absorbent and exhalent functions are modified in other ways by the chemical composition of the bath. But the whole subject stands in need of further inves- tigation. 4. The warm bath modifies the texture of the skin ; at least the bath of water and watery vapour. This effect arises partly from imbibition, and partly from a specific action on the animal fibre. It is greatly less on living bodies than on those which have become dead ; but still it is conspicu- ously marked in them. The ultimate effect is to soften, to expand, and to relax the parts with which the fluid is in contact; and it would appear that its relaxant influence extends to parts with which it is only mediately in contact. After immersion in the warm bath, for a considerable time, not merely the muscles of the limbs, but even the abdominal viscera appear to have lost a portion of their solidity and tension. Much of the relaxing property of the warm bath on the surface of the body is no doubt derived from the temperature ; as we know that the cold bath has, in a considerable degree, the very reverse opera- tion. Yet a good deal must be attributed to the effect of the water independently of the tempera- ture, since we find, firstly, that even cold water, if long applied, produces a softened state of the skin ; and, secondly, that dry heat, or heat con- veyed through the medium of air, does not produce similar effects. 5. The warm bath modifies the frequency and force of the action of the heart. This is suffi- ciently shown by its well-known effects on the pulse. The precise effects of the bath in this way depend on many circumstances, some having reference to the patient, and some to the bath. In general it may be said that when the degree of heat communicated is moderate, and the sensi- bility and irritability of the subject are not exces- sive, the change produced in the frequency of the pulse is not remarkable. If the medium is water, and the temperature does not exceed 97°, although the pulse and respiration may be slightly quickened upon the patient first entering the bath, yet after a short time, when the surface and extremities have become moderately but thoroughly warmed, and the nervous system accustomed, as it were, to the new stimulus, the heart and lungs resume nearly their natural action. The pulse may be somewhat fuller, but, in general, is not increased in frequency. When the temperature is raised to the full heat of the blood (98°), it will, in most cases, slightly augment the power and fre- quency of the heart's action. At still higher tem- peratures, the pulse becomes considerably in- creased in frequency, and in a degree proportioned to the temperature ; and if this is carried to the highest point at which it can be sustained, the frequency becomes extreme.* When so much excited, the pulse occasionally continues quick for several hours after the bath, and in some cases * See the experiments of Dr. Parr in his Thesis de Balneo, F.din. 1773, and in his Medical Diet. Art. Bal- neum; of ForAyce, Blagden.aiul Dobson in Philos. Trans. vol. lxv p. 11], 463, 484; of Delaroche and Berger, Journ. de Physique, tomes 63, 71, 77; of Eostan, Diet, de Med, u ii. Art. Bain. it does not regain its natural standard, until after the patient has had a night's rest 6. The warm bath modifies the relative distri- bution of blood throughout the system; more espe- cially the relative proportion of this in the exter- nal and internal parts. When a disproportionate quantity exists in the internal organs, the wann bath recals it to the surface, and in various ways: lstly, by exciting the superficial capillaries to in- creased action; 2dly, by relaxing and dilating the external tissues, so as to render them not merely capable of containing more fluid, but to force them, by a physical necessity, to draw an additional supply from other parts; 3dly, by directly reliev- ing the local irritation on which the internal con- gestion may depend. It is to be observed, however, that this equal- izing power of the warm bath only exists when the temperature is of that moderate degree which does not excite the heart to preternatural action. If the stimulus of the heat augments the force and frequency of the heart's contractions considerably beyond the standard of health, although much more blood than before may be attracted to the surface, the internal parts are not unloaded in the same proportion. On the contrary, the whole vascular system being stimulated to increased action, and the contained fluids being in some degree dilated by the increase of the temperature, an increased quantity of blood is thrown into the capillaries (at least in the same space of time) in every part of the body. 7. The warm bath increases the volume of the superficial parts of the body and of the general mass of circulating fluids, in proportion to the degree of temperature communicated to the sys- tem. This effect is obvious on the surface gene- rally, and is demonstrated in parts capable of ad- measurement. Rings on the fingers, which we had occasion to notice as becoming loose in the cold bath, in the warm bath fit more tightly, the soft parts on both sides frequently swelling con- siderably beyond the diameter of the ring. The same thing is shown by the greater difficulty of putting on tight shoes after the warm bath. Some physiologists attribute the principal results ob- served in the applications of the hot bath to the expansion of the fluids. No doubt it must have a certain effect, but by no means to the extent which has been supposed. The effect of heat as a stimulus exciting the heart to increased action, and thereby throwing the blood with greater force and rapidity through the whole vascular system, is of much greater consequence than its physical dila- tation. It must be recollected that the universal and intimate penetration by the blood of all the solid tissues will soon raise them to the same temperature as this fluid, and, expanding them proportionally, will remove the evils that might arise from an over-distension caused by a dispro- portion between the vessels and their contents.]- § 2. Of the Warm Bath, strictly so called, (water from 92° to 98°.) The general effects of the warm bath have been mostly noticed in the last section; but we shall give a brief recapitulation of them here, for the t Is it probable that the impossibility of distension of the brain, within the solid cranium, is one reason why [he effects of baths of very high temperature are particu- larly felt in the head t * BATHING. 277 convenience of practical reference. The warm bath possesses at once the somewhat opposite powers of exciting and soothing the nervous and vascular systems. Its power of soothing the ner- vous system is direct and obvious; its power of exciting is, in general, confined within- the limits of natural or healthy action. It may be said rather to prompt to normal action than to excite. It acts as a direct but gentle stimulus to the skin, augmenting the quantity of its blood, and at the same time relaxing its texture. It produces a more general and equable distribution of blood throughout the whole system; and, in a more especial manner, derives it from the internal parts to the surface and extremities, without, at the same time, giving rise to undue action or irregu- lar determinations to particular parts. By these various actions it universally promotes absorption and re-action. Its ultimate effects are to soothe and refresh the whole system, and, at the same time, to render all its functions freer and of more ready performance. When its operation is pro- longed, the soothing and relaxing effects become progressively more and more predominant, while the gentle excitement proportionally decreases. By these various modes of influencing the system, it is capable of fulfilling various indications in the treatment of diseases, according to the mode of its application, and the particular state of the sys- tem at the time. By relieving pain and irritation, it acts as a sedative; by restoring deranged func- tions, and rendering them of more ready perform- ance, it acts, like the cold bath, as an indirect tonic. By its soothing effect on the nervous sys- tem, and its general powers of relaxing, it is an antispasmodic. By modifying the circulation in the extreme parts, it is strongly derivative ; by its action on the skin, it is directly diaphoretic ; and by more or fewer of these modes of action com- bined, it becomes a powerful alterative. It acts in several other ways, to which it is not easy to give a formal designation, but which will be understood from what has been stated in the pre- ceding section, and what we are now about to deliver. Medical uses of the warm bath.—In treating of the employment of the warm bath, it has been customary to consider it under two heads, as hygeienic and therapeutic, or preventive and cura- tive. As, however, the bath is never necessary in the state of perfect health, and as most of the con- ditions of the body in which it has been recom- mended, are, in fact, deviations from this standard, and therefore, in strictness of language, morbid, although perhaps not formally designated as dis- eases—it is obvious that this classification is not quite accurate. We shall, nevertheless, so far comply with the customary arrangement as to notice, in the first place, the milder forms of disor- der ; and secondly, the more formal diseases. I. The following are a few of the cases of milder disorder, in which the warm bath is highly beneficial:— 1. In fatigue after great muscular exertion, particularly if long continued, as from fencing, boxing, hard walking or riding, playing at any laborious game, as cricket, racket, &c. In these cases, the body should be allowed time to cool before the bath is taken, and the temperature of this should not be higher than is absolutely ne- cessary to produce the desired effects. In general, 94°, 95°, or 96° will be sufficiently high. 2. After a long journey, more particularly in the case of persons of a delicate or feverish habit Travelling for several successive days, even in the easiest carriage and on the best roads, pro- duces, in almost every person, dryness of skin, irregular distribution of blood, defective secretion and excretion, general irritation of the nervous system, and a slight degree of feverish heat. In irritable subjects, and still more in persons affected with some chronic inflammation, or tendency to such, the excitement from travelling often leads to serious consequences if not speedily allayed. In such cases the warm bath is an invaluable remedy ; and, when combined with repose and abstinence, and a gentle aperient, may be regarded as almost specific for safe travelling. 3. In sedentariness from any cause. Also after long-continued mental excitement and loss of sleep, whether accompanied by sedentariness and seclusion, and inactivity of the external senses, as in the labours of the study; or with bodily exertion and activity of the external senses, as in many departments of public and professional life, or in the no less laborious avocations of fashion- able dissipation. 4. The warm bath is very beneficial in nume- rous other slight disorders of the system, from whatever cause arising, and whether of a chronic kind, or the harbingers of acute diseases. Of this sort are irregular determinations of blood, parti- cularly congestions in the internal organs, and recession of it from the surface and extremities ; nervous irritations of all kinds, and disposition to spasmodic affections; a dry and harsh state of the skin, either with a disposition to feverishness, or with coldness of the surface; the reverse state of relaxation of the skin, with a disposition to clam- miness and cold perspiration, &c. &c. II. The warm bath is beneficially employed in numerous diseases of a more formal and serious kind, and of very different characters. We can onry refer to some of those in which it is most useful :— 1. Chronic nervous diseases of a spasmodic kind, unaccompanied by a plethoric state of the system, or by fever, and not dependent on an in- flammatory condition of the nervous centres. Of this kind are cramps, spasms, convulsions of various kinds, and particularly the convulsive affections of infants, whether depending upon idiopathic or sympathetic irritation of the nervous system. The last-named qualifications must be strictly attended to, otherwise the bath may be productive of great mischief, as we have reason to know that it often is from such neglect. We shall have occasion to notice the cautions neces- sary in such cases hereafter. 2. Various painful affections, chiefly of a nerv- ous or spasmodic nature, occurring in spare habits, and without inflammation, or with a degree ex- tremely disproportioned to the severity of the pain. Of this kind are the numerous forms of neuralgia, including sciatica and lumbago, gastralgia, and colic; also gall-stone, nephralgia, stone in the ureter, bladder, urethra, &c. 3. Certain acute inflammations, more espe- 278 BATHING. cially of the mucous membranes of the abdominal and pelvic viscera, when accompanied by great pain. Of this kind are certain forms of enteritis, gastritis, inflammations excited by and accom- panying gall-stone and urinary calculi ; some forms of dysentery, diarrhoea, cystitis, hysteritis, &c. In all these cases, or with very rare excep- tions, previous loss of blood, both generally and locally, will be necessary to constitute the bath a useful, or even a safe remedy. With such pre- paration, however, and if not contra-indicated by the plethoric habit of the patient, or other circum- stances, the bath, at a temperature not exceeding 97°, is often extremely beneficial. In the class of cases now under consideration, a great mistake is frequently committed by the practitioner overlooking the inflammations which accompany the pain and spasm, and prescribing at once opium and the warm bath, without any attempt to lessen, previously, the violence of the local affection, or the general fever, by proper depletion. In instances of this sort, the bath, more especially if administered at a high tem- perature, as it often is, has a direct tendency to aggravate in place of relieving the disease. 4. Certain chronic inflammations, congestions, or irritations of several of the same parts, not essentially of a painful kind. Of this sort is that extensive class of diseases of the intestinal mucous membrane, commonly arranged by French writers under the general name of chronic gastro-enteritis, and indicated in different cases by the common symptoms of dyspepsia, constipation, diarrhoea, &c.; also chronic inflammations or irritations of the uterus, vagina, bladder, kidney ;—dysmenor- rhcea, dysury, amenorrhoea, leucorrhcea, &c. In most of these cases local bleeding will be proper previously to the administration of the bath ; and in several of the affections of the pelvic viscera, the hip-bath will frequently be preferable to the general bath. In no class of cases is the warm bath more strikingly beneficial than in those affections of the stomach and bowels which are commonly ranged under the head of dyspepsia. This *re- mark is more especially applicable to the forms of this affection in which there co-exist a fixed local irritation in some part of the bowel, an un- healthy state of the skin, and an irregular distri- bution of the blood, more particularly on the sur- face and extremities. And we may add that there are few if any cases of dyspepsia, of long standing, in which one or more of these states do exist. It is well known that the skin has a much more intimate sympathy with the mucous mem- branes than with the parenchymatous viscera ; and this truth is in no case more strongly mani- fested than in the effect produced by the warm bath in affections of the gastro-intestinal mem- brane. Besides its direct effect in this way, through the medium of the nervous system, it acts at the same time locally on the skin as a powerful derivative, and as a means of equalizing the circulation in the central and extreme parts. A sensible remark, made by M. Rapou, in speak- ing of the effect of the vapour-bath in this disease, is equally applicable to the warm bath. He says, that chronic inflammations of the mucous mem- brane of the stomach and bowels are frequently confounded with diseases of a very different kind, such as nervous dyspepsia, gastralgia, &c In cases of the last-mentioned kind, antispasmodics, bitters, tonics, &c, will often be beneficial; while they will be extremely injurious in the former,— the irritation of the membrane being thereby fre- quently excited to inflammation ; or, if this al- ready exists, it will be greatly aggravated. In both classes of cases the warm bath is at least a safe application ; and, with very few exceptions, it is a most salutary one. Its administration is therefore not affected by error in diagnosis. We may add that it is in the very cases where internal remedies are most prejudicial, that the warm bath is most beneficial; namely, in irritated states of the mucous membrane, accompanied either with obstinate costiveness or a tendency to diarrhoea, or the one alternating with the other. From its action in such cases, the warm bath may be said to be at once laxative and astringent; and when its use is combined with proper diet and exercise, or, at most, with a few leeches to the praecordia or anus, cures will often be effected by it, in cases of long standing, with little or no aid from me- dicine. Cxteris paribus, the warm bath is the more indicated in dyspepsia the more the surface deviates from the healthy state, whether in regard to the distribution of the blood in it or to its functions as a secreting and excreting organ. 5. The warm bath is beneficial in various chronic diseases of a general and cachectic kind, attended by great functional derangements of im- portant organs, and generally by a depraved state of the blood, as well as an irregular distribution of it Of this kind are gout, general disorder of the system from long-protracted dyspepsia and loaded bowels, diabetes, chlorosis, &c. &c. Few questions were formerly more agitated among medical men than the propriety of warm bathing in gout, and more particularly of the warm waters of Bath. The zeal with which the ques- tion was regarded has, however, greatly lessened in our time; partly because longer experience has tended to solve it more satisfactorily, and partly because some progress has been made in ascertaining the pathology of gout. Diseases in general, and this among the rest, are not now treated on principles so completely empirical as formerly. In viewing gout in relation to its treatment by warm bathing, we may, in a great degree, although not entirely, dismiss from our minds its specific nature, and prescribe the bath on the same prin- ciples as in other diseases. In the great majority of cases, we consider it as totally inadmissible in the inflammatory stage of gout. In the intervals of the disease it is extremely applicable to many of the functional and other derangements that complicate it, or constitute an important part of it; but the propriety of its administration in in- dividual cases must entirely depend on the parti- cular state or degree of these derangements, or on other states of the system with which they may be combined. The great objection to the use of the warm bath in gout is the state of general plethora with which this disease is so constantly connected. It is chiefly the absence of plethora which permits the bath to exert its beneficial , effects in many other diseases of a still more in- BATHING. 279 flammatory nature than gout; and if we have I removed this condition effectually in gout the ' presence of some inflammation in the joints is not a necessary contra-indication to its use. In the general state of disorder in which gout originates, viewed abstractedly from the accompanying ple- thora, there is no single remedy more valuable than the warm bath ; in the intervals of gout, therefore, after proper depletion, we recommend i its use in the strongest manner. 6. The warm bath is useful in many chronic diseases of the external subcutaneous textures, with or without general disorder of the system. Of this kind are chronic rheumatism, the local I sequelae of gout, nodosity and other chronic af- fections of the joints, partial paralytic affections, muscular contractions, &c. In many of these cases the local bath, in the form of douse or va- pour, is preferable to the general warm bath, more particularly when combined with the operations of friction, champooing, &c* 7. A great number as well as a great variety of chronic diseases of the skin, both idiopathic and sympathetic, are greatly benefited by the warm bath in one or other of its forms. In such cases the bath acts directly as a topical remedy modifying the actual state of the skin, as well as a means of improving the general health and the internal disorders with which the cutaneous dis- ease may be connected. This is the class of cases in which impregnation of the water with various saline or vegetable matters dissolved or diffused in it, is more especially useful, and in which the stay in the bath may be prolonged much beyond the usual period. When not otherwise contra- indicated, it may be extended to two or more hours. 9. The warm bath has been used, more par- ticularly on the continent, in the cold stage of severe fevers, and in the retrocession or imper- fect development of some acute exanthemata. In such cases, it is employed with the view of at once stimulating the skin topically, and deriving from the internal organs. The employment of the remedy, however, in such cases requires great discrimination, and we think it necessary to cau- tion the young practitioner against its general use. In fevers of long standing, marked by much ner- vous irritation, harsh dry skin, &c, the warm bath of a low temperature—or the tepid bath— is very beneficial. Many other diseases may be mentioned in which the warm bath is occasionally found to be a very valuable remedy; but we cannot here take notice of all such cases. We trust that enough has been stated to guide the inexperienced prac- titioner to a safe application of the remedy in most instances that may present themselves. Cautions and contra-indications in the use of the'warm bath.—There are few remedies more frequently misapplied than the warm bath, or whose misapplication is of more serious ill-con- sequence. It cannot be expected that we should * In many cases of this kind the local bath invented by Dr. Blegborough, and termed by him the air.pump vapour-bath, is extremely useful. This apparatus com- bines the advantages of dry cupping with the stimulant or relaxing effects of the vapour bath. See Facts and Observations respecting the Air-pump Vapour-bath. By R. Blegborough, M. D. Lond. 1803. here enumerate all the cases in which it may be misapplied, or all the cautions that are requisite in prescribing it These must, in a great mea- sure, be derived from the general principles that regulate its administration ; but every practical physician must be well aware how frequently the principles must be modified in their application to individual cases. The warm bath is either altogether contra-in- dicated in the following cases, or is not to be em- ployed without great caution or previous prepa- ration :— 1. In very gross, full habits ; in plethora of all kinds, in great obesity. 2. In persons predisposed to apoplexy or de- termination of blood to the head, hemorrhage, particularly haemoptysis. It is equally improper in most organic diseases of the heart and great vessels ; and, in general, in all cases, in which the excitement of the circulation or expansion of the fluids is likely to prove injurious. In these cases the risk, generally speaking, may be said to be proportioned to the heat of the bath ; and we are far from asserting that a bath of a mode- rate temperature may not be safely administered, under proper restrictions, in many of the diseases now alluded to. Previous depletion, as we had formerly occasion to observe, will often enable us to use the bath of a moderate temperature in in- flammatory diseases, more particularly such as are accompanied with pain, or have their seat in the mucous membranes. 3. In great relaxation of the system, with a tendency to dropsy. In cases of this kind the tepid bath, however, will often be useful. 4. In extreme sensitiveness of the surface, and in persons in whom the pressure of the water occasions great precordial distress. In these cases the vapour bath is often well borne and is very beneficial. A little management will often get over the difficulties mentioned in this paragraph. 5. In all febrile diseases, whether accompanied with visceral inflammations or not, where there is an active circulation and a hot dry skin. 6. During the presence of the catamenia, ex- cept in cases of great urgency. The warm bath may be used in pregnancy, more particularly in the early months, but not without considerabl« caution. The contra-indications to its use must be found in individual cases ; but it may be stat- ed generally that pregnancy, in relation to the warm bath, is to be viewed as a state of excite- ment, if not as an inflammatory disease. Many other grounds for its cautious employ- ment, and also for its total prohibition, have been noticed in the preceding pages; to these and to the principles on which the general administra- tion of the remedy is founded, we refer the read- er. We would here only add one important rule which should never be lost sight of in prescribing the warm bath, or, indeed, any other powerful remedy__and this is, never to recommend it in any disease without proper examination of the individual case. Much practical mischief is tha consequence of neglecting this cardinal canon of therapeutics. Examples of this truth might be drawn from most diseases in which the warm bath is used. Thus we have stated that it is a most valuable remedy in chronic dyspepsia, gout, &c. 280 BATHING. &c, but it is so only provided there exists no ac- tive inflammation, general plethora, or other anal- ogous complications. In many of these cases the bath will be found extremely beneficial after loss of blood, purging, or low diet; although before these were had recourse to, it might have been not merely useless but very injurious. Infantile con- vulsions occur to us as another case in point Generally speaking, the warm bath is extremely beneficial in this class of diseases ; but it is found to be sometimes no less prejudicial, when applied without due examination of the peculiarities of individual cases. In plethoric and gross children, a very considerable proportion, the local abstrac- tion of blood from the head, and the complete unloading of the alimentary canal, are often ne- cessary to render such a measure beneficial, or even free from danger. Practical administration of the warm bath.— Under this head we shall embody various import- ant points which require particular attention in using the warm bath as a therapeutic agent, and with which, therefore, the practitioner ought to be well acquainted. 1. Temperature of the water.—The exact de- gree of heat, between the limits 92° and 98°, that is to be prescribed, must be regulated by the pecu- liarities of individual cases. In certain states of disease, and in particular constitutions, the same degree of temperature will be productive of very different effects on the feelings of the patient and on the system at lar^e. It may be stated as a general rule, not however without many excep- tions, that any degree of temperature may be se- lected between 93° and 97°, which is most agree- able to the feelings of the patient. Many persons will prefer a higher temperature than the last named degree, but few lower than the first. If the patient's feelings require it, and there is no particular contra-indication in the case, the tem- perature of 98° may be allowed ; but we must on no account go above this, if our object is to refresh and soothe, not to stimulate and exhaust. The temperature of 95° or 96° is, on the whole, that which is most generally pleasant and beneficial at the same time; and if either of these is found sufficiently high to maintain the feelings of com- fortable warmth, through the whole period of the bath, the temperature must not be raised. If a lower temperature, however, is found more agree- able, this may, in most cases, be allowed at the will of the patient. Generally speaking, in the warm water bath, the same degree of temperature must be kept up dur- ing the whole period of immersion ; and this will easily be effected by the addition of a small quan- tity of hot water about a quarter of an hour after the patient has been in the bath.* The temper- ature must always be ascertained by the thermo- meter in the first instance ; and the subsequent ad- ditions of water are to be regulated by its indica- * Considerable difference is observed in the rapidity with which the warm bath cools; dependent on the ma- terials and construction of the bath, its size, the circum- stance of the same bath having been previously used or not, the temperature of the bather's body generally, the degree of motion kept tip in the water, &c. &c. The only safe mode of regulating the temperature is by keep- ing a thermometer constantly in the water, to be observ- ed from time to time by the patient or attendant. lions, and not by the feelings of the patient Great mistakes are often committed through neg- lect of this rule, the temperature being gradually and imperceptibly raised much above that of the warm bath, with the entire frustration of the ob- jects with which the remedy is prescribed. 2. Period of stay in the bath.—The time of the immersion, like the temperature, must be de- termined by the practitioner in each case, accord- ing to the nature of the disease, the constitution of the patient, and the object for which the bath is prescribed. Speaking generally, a quarter of an hour may be said to be the shortest period, an hour the longest, and twenty-five minutes to half an hour the medium. Periods greatly longer than these, however, are very common, more particu- larly on the continent, and are, no doubt, very proper and useful in certain cases. In the mine- ral water baths at different places in Germany and Switzerland, persons are accustomed to con- tinue several hours consecutively in the bath, and even repeat the immersion after' a short interval, so as to remain in the water eight, ten, and even twelve hours in the course of one day. The effects of the bath are, in all cases, greatly modi- fied by the length of the immersion. It may be stated as a proposition generally true, that the bath, at the temperatures now under consideration, is more relaxant and deobstruent the longer it is continued. If at all approaching the temperature of the blood, it has always some stimulant effect at first, and it is only after this has completely subsided, that the relaxing effects are fully expe- rienced. For this reason the same bath may be exciting if continued only ten or fifteen minutes, and soothing and relaxing if continued twice or thrice as long. It is not merely in cutaneous dis- eases, in which one of the principal objects is to produce a decided change in the affected parts by the local action of the fluid, that the immersion for several consecutive hours is recommended; the same practice is capable of producing very beneficial results in various chronic diseases of the internal organs. The least consideration of the subject, independently of experience, must lead to the conclusion, that an action of this kind, kept up for so long a time on the whole cutaneous surface, must have a powerful effect as a revulsive, and occasion important changes in the condition of the internal organs. We are of opinion that this mode of employing the warm bath is too little practised in this country. It can only be conve- niently obtained at thermal springs, where alone large bodies of water of the proper temperature are always to be had, and where alone, conse- quently, the large or plunge bath of this temper- ature is to be found. So prolonged a stay in the common solitary bath would be altogether intoler- able. Admirable opportunities for this kind of bathing are, however, afforded by the large mine- ral baths at Bath in this country, and at many places on the continent. The Queen's Bath, or the Cross Bath, at the former place, is exactly suited to the purposes now contemplated, being of the temperature best adapted to effect them, namely, from 94° to 96°. 3. Time of using the bath.—This, like the pre- ceding circumstances, cannot be absolutely fixed. When prescribed in acute diseases, the bath must, BATHING. 281 of course, be employed at any time when needed. In chronic diseases, or when used as a measure of hygeiene, the hour of bathing may be fixed. It is the practice at Bath, and some other mineral springs, to bathe early in the morning; but we apprehend this practice is adopted as much from motives of convenience as because this time is deemed preferable. On the contrary, we should say, as a general rule, that the best time for bath- ing is between breakfast and dinner, either two or three hours after breakfast, or an hour and a half before dinner. The latter period has this advan- tage, that the patient is less tempted to expose himself to the open air after the bath. 4. The conduct of the patient while in the bath, as also previously to its use and afterwards, de- serves some notice, although this is of less mo- ment, perhaps, than in the case of the cold bath. It is proper to enter the bath in as tranquil a state, both of body and mind, as possible. The patient, therefore, must not bathe while greatly heated with exercise or stimulated by a recent meal, more particularly after drinking much wine. A state of chilliness or coldness forms no objection to the bath. While in the bath, the whole body should be covered with the water, or rather the parts that have been once immersed should not be left ex- posed to the air. Friction, with a coarse cloth or with the flesh-brush is generally to be recom- mended. In the large baths which admit of loco- motion, this will, as a matter of course, be used, and should be used. After the bath, the patient should not unneces- sarily expose himself to the open air for some time, especially if the weather be cold; and it may be stated as a good rule for him to remain quietly in the house for an hour after the bath. It is not, however, intended to be asserted that there is, in general, much, or indeed any risk in the pa- tient going abroad immediately on coming out of the bath : on the contrary we believe that there is much less risk of catching cold immediately on coming out of the bath than afterwards ; and, except in the case of very delicate or diseased persons, there is no objection to the patient walk- ing from the bath to his own home, if at no great distance. We, however, consider it better that no unnecessary exposure or considerable bodily exercise should be taken for an hour or two after bathing, for the same reasons that we deem them improper after blood-letting or any other import- ant therapeutic operation. When one of the objects of the bath is to excite much sensible per- spiration, it will be proper for the patient to go to a warm bed after it, to place himself between blankets, and remain there as long as the perspi- ration continues. When the object is not to excite perspiration, the patient should not go to bed, but dress himself in his ordinary clothing. It is a slight circumstance, but one deserving notice in this place, because of some consequence, and often neglected, that the towels used for dry- ing the body should be always warmed, and, of course, thoroughly dry. 5. Repetition of the bath.—The frequency of repetition of the bath, like the other circumstances connected with its exhibition, must be regulated by the exigencies of individual cases. One bath Vol. I___36 r* daily is the maximum of frequency, (except in certain cases formerly noticed;) once a week, the minimum. The most usual, and upon the whole the best rule is—to take the bath every second day, or, at least, every third day. The length of time that a course of warm bathing is to be con- tinued cannot be at all fixed, except in individual cases ; and then only by observing the effects of the remedy. 6 Form of the bath. — The special mode of applying the warm bath is not a matter of indif- ference. It is true that, in a great majority of cases, the common small bath, in which the pa- tient is immersed in the semi-recumbent posture, answers every purpose for which the bath is ad- ministered. In some cases, however, more par- ticularly where the immersion is greatly pro- longed, the constrained position in which this bath is taken cannot be borne. In such instances the large open bath, which admits of locomotion, is greatly to be preferred. Even independently of the relief from the uneasiness of a constrained position, there are many cases in which the free movements permitted in the large bath are directly beneficial. Of this kind are local affections of the limbs and joints, in which the contemporane- ous use of free motion and friction while in the water is of the greatest benefit. The advantage is no less evident in many cases of internal dis- ease. We hold it therefore far from a matter of indifference in every case, which of the two forms of bath is used ; and on this ground alone it will frequently be proper to give the preference to Bath as a place of resort for the invalid for whom warm bathing is recommended,—this being the only place in England where the warm bath, with the full benefit of locomotion, can be obtained. 7. Influence of saline impregnations in modi- fying the effects of the warm bath.—In the pre- ceding observations, we have spoken of the water bath, without regard to its impregnation with saline or other extraneous substances. It is, however, necessary to notice these in this place. This subject is, perhaps, less regarded in this country than it ought to be. Many persons seem to consider only the temperature, deeming it a matter of indifference whether the water is that in common use for domestic purposes, or is that of the sea or of mineral springs. This is a very great mistake, and can only arise from inexperi- ence or want of observation. Two or three trials on delicate and relaxed subjects will suffice to convince any one that the two kinds of baths are productive of very different effects. In general it may be stated that water containing mineral and saline substances in solution, is less relaxing and consequently more tonic than pure water. Such compound baths can be borne for a longer period, and are followed by less exhaustion than baths of pure water. Patients are also less liable to take cold after the former. When, therefore, the object is to produce great relaxation and exhaus- tion, as in certain cases of acute inflammation, pain, or spasm, the pure water bath is to be pre- ferred ; while, on the other hand, the saline or mineral water bath is to be administered if the object is not to exhaust but to refresh. In cuta- neous diseases, sometimes one kind of bath will be preferable, sometimes another, according to thu 262 BATHING. nature of the case. The compound bath is cer- tainly more stimulant to the skin, consequently more derivative from the internal parts ; and this circumstance will, no doubt account for much of the difference observed between the two kinds of bathing. It would, however, be both unphiloso- phical and unjust to consider the chemical com- position of the water as a matter of indifference, provided the same degree of stimulus were com- municated by it to the skin. Without pausing to examine the question as to the absorbing powers of the skin, and the actual transference of the materials of the bath into the blood through this medium, it is a matter of simple observation and fact, that the effects of bathing vary with the nature of the chemical composition of the fluid. The warm baths attached to the mineral springs of Bath, Buxton, Cheltenham or Leamington, Harrogate, Matlock, and Tunbridge-Wells, have each peculiar effects. The warm sea-water bath differs from all these; and, although the differ- ence may not be often appreciable, there is no doubt a difference even in the action of river, rain, spring, and hard and soft pump-water respectively. In the cases in which the saline bath is considered preferable, an easy and in general an effectual substitute is afforded by the addition of common salt to plain water ; and it will be found, in prac- tice, that such addition is to be recommended in the majority of cases in which the warm bath is prescribed medicinally. When used as a measure of hygeiene, the saline bath is in almost all cases to be preferred. § 3. Of the Tepid Bath, (temperature of the water from 86° to 92°.) The effects of the bath of a temperature con- siderably below that of the body, yet still commu- nicating the sensation of warmth to the surface, are similar in kind to those of the warm bath, but inferior in degree. Generally speaking, the tepid bath is less pleasant, less animating, less soothing. It possesses neither the direct stimulus of the warm, nor the indirect stimulus of the cold bath. When prolonged, in place of the tranquillizing effects produced by the warm bath, it gives rise to a gradually increasing sense of chilliness and dis- comfort. Caloric is carried off' from the body faster than it is produced, while the unstimulating and relaxing medium has no power, like the cold bath, to rouse the vital energies of the system to increased vascular action and augmentation of the processes that produce animal heat. In its medi- cal effects, as well as in its thermometrical charac- ter, the tepid bath may be said to occupy a middle position between the temperate and warm baths. In all cases where we consider the warm bath indicated, but are apprehensive that from particu- lar circumstances it may prove too exciting, we must of course reduce the temperature to the degree that can be borne. We formerly had occa- sion to observe that only the very lowest degrees of the warm bath are found tolerable by some persons; and we may add that, in some rare cases, even a still lower temperature is necessary. In such individuals the tepid takes the place of the warm bath as a matter of necessity. On the other hand, among the class of persons whose cases are commonly benefited by the temperate bath, some will be found whose peculiarity of habit will require the temperature to be raised within the limits of the tepid bath. Besides these cases requiring the tepid hath from the idiosyncrasy of the patient, there are others which require it from the peculiar character of the affection. Of this kind are various mild febrile diseases connected with much irritability and a dry harsh skin ; morbid states of the skin itself, in which there exist, at the same time, a very irritable and a dry and heated state of it. There are many other cases in which the tepid bath is beneficial, and which will readily suggest themselves to those who understand the principles on which the cold and warm baths are prescribed, and are practically conversant with their effects. Our limits oblige us to be contented with this general reference, and the very imperfect outline here given. § 4. Of the Hot Bath, (temperature 99o and upwards.) This bath is a powerful but temporary stimulus to the skin and to the nervous and vascular sys- tem, and in a degree proportioned to its tempera- ture. In the state of health, and in disease gene- rally, it has no soothing effects ; nor does it, like the warm bath, gently solicit and encourage the natural actions of the system, but impels them suddenly, forcibly, and irregularly. It tends more to disturb than to equalize action. The heart being powerfully excited, the blood is forced with rapidity through the whole vascular system, the pulse being raised ten, twenty, and even fifty pul- sations in the minute, and increased proportionally in strength. This preternatural force of the cir- culation is felt in a particular manner in the head. The carotids are seen and felt to beat powerfally, and headach, giddiness, and other cerebral symp- toms are of frequent occurrence. The combined effect of the increased action of the heart and the direct stimulation of the skin by the local heat, occasions a great afflux of blood to the surface, which becomes universally red and swollen. This determination of blood to the surface does not, however, like that produced by the warm bath, relieve the internal organs ; on the contrary, it is very generally accompanied by great and irregular determination of blood to these parts. The great tension on the surface is, after a time, relieved by the breaking out of a general sweat on all parts not covered by the bath; and there is reason to believe that the same takes place on the parts that are immersed. The other secretions are, like the distribution of the blood, irregular and uncer- tain, some being increased and others diminished. If the bath is continued, although the pulse re- mains quick, the general excitement is speedily followed by universal languor, lassitude, and de- bility; and torpor and somnolency surpcrvene from exhaustion of the animal powers, as in the case of the warm bath they had been induced by the tranquillizing influence of the remedy on the sensations and the nervous system generally. In their action, both the warm and hot bath are stimulant to the nervous and vascular systems, but in very different degrees and with very diffe- rent results. The primary effect of the former may be compared to that of a moderate meal of plain and wholesome nutriment; that of the latter to the potent and sudden stimulation of vinous or BATHING. 283 other strong drinks; and their ultimate effects may also be said to be analogous. The gentle stimulus of the warm bath remains some time after its application, beneficially prompting and aiding the healthy actions of the system, and gra- j dually vanishing in the habitual conditions of health; the hot bath, on the contrary, excites beyond the limits of safety, disturbs the normal actions of the system, and then suddenly disap- pears, leaving behind it exhaustion and debility, and frequently disease. The warm bath is in common use as a measure of hygeiene and for luxury, as well as a curative agent. The hot bath is exclusively therapeutical, and its employment in this way is very circum- scribed. We had occasion formerly to remark that there are certain peculiarities of constitution and states of disease where it is necessary to raise the temperature of the water above that of blood heat, before the ordinary effects of the warm bath are experienced. In ordinary cases, however, the bath at this high temperature produces the effects just described, and these are obviously of a kind which render it improper as a remedial measure in the great majority of instances in which the application of heat to the surface can be supposed to be indicated. The hot bath is, nevertheless, a valuable remedy in certain cases. Owing to its highly stimulating and exciting qualities, it is applicable to morbid states in which the warm bath, if not injurious, is at least of inadequate power; as, for instance, when we wish to produce a great and rapid excitement either of the general system, or only of the skin, or of both at the same time. It is therefore applicable in the following and other analogous cases : — 1. In extreme exhaustion, with a cold shrunk state of the skin and superficial parts of the body, and a concentration of the circulating fluids and the nervous energy in the internal organs. Exam- ples of this morbid state are furnished by spas- modic cholera, certain forms of pernicious fever, ague, &c. 2. In sudden retrocessions of cutaneous dis- eases, both of an acute and chronic kind; scarla- tina, measles, &c. &c. &c. In certain inflamma- tory affections of the internal organs, in which the circulation is equally concentrated in the interior of the system, and the pulse is too feeble and 6mall to allow venesection to be performed : some forms of enteritis and gastritis, as from retrocedent gout are of this kind ; but the utmost caution is requisite in applying the remedy in all such cases. 3. In chronic diseases of the skin. In this case the bath is used chiefly as a topical remedy in some of the most obstinate and indolent forms, with the view of exciting the skin, and altering its physical and vital condition. Its application in cases of this kind requires great discrimination and caution ; but with the proper care it is capa- ble of being made a very powerful remedy. 4. In certain cases of paralysis of long standing, when there are no grounds for apprehending that the stimulating effects of the bath may induce fresh disease within the head. The very existence of the paralytic state frequently renders the sys- tem less susceptible of the stimulus of heat; and when this is the case, there is no doubt that an application so powerful and extensive as the hot bath must in many cases be productive of excel- lent effects. This remedy is in great use at Bath in such cases; the patients being accustomed to remain in water, of the temperature of 104°, up- wards of an hour without suffering any inconve- nience, and frequently with much advantage. In most of the cases above mentioned, the object is to obtain the stimulating and not the debilitating effects of the bath ; it ought, therefore, to be used at the highest temperature that is deemed proper, and continued only for a very short period. All the cautions and contra-indications formerly delivered respecting the use of the warm bath, are still more necessary in the case of the hot bath. § 5. Of the Vapour Bath. Forms of the vapour bath and modes of using it.—In treating of the warm bath it was almost unnecessary to notice the particular forms in which it is administered, as these differ very little from each other, either in their nature or effects on the system. The case is different with the vapour bath ; there being several modes of applying this, which are productive of results respectively diffe- rent There are two principal forms of this bath : — 1. The free or public vapour bath, steam chamber or humid stove, bagnio, Russian or Oriental bath. 2. The confined or solitary vapour bath, such as is commonly used in this country. 1. The free or Russian bath consists of a close room filled with vapour, in which the patient may move about at pleasure, and where many persons may bathe in concert The chamber is commonly of considerable dimensions, and is arranged some- what in the manner of a theatre, with benches rising one above another. In the Russian and German baths the vapour is produced within the apartment by throwing water from time to time upon red-hot stones, heated by a furnace under- neath. By this process the whole room is soon filled with vapour, heated to a temperature vary- ing from 112° to 160° or 180°, the heat, owing to the diminished gravity of the air, being pro- gressively greater with the elevation of the benches. In the best arranged establishments there are various other apartments connected with the bathing-chamber. The bathers first enter an ante-room, not containing any vapour, but heated to the temperature of from 75° to 80°, where they take off their ordinary clothing, put on a proper dress, and then enter the bath. On first commencing the use of the bath, the patient com- monly remains on the lower benches, where the temperature varies from 112° to 120°. At the successive visits he progressively ascends the benches until the temperature is 130° to 140°. During the bath it is customary to rub the body with soap-suds, wheaten-bran, &c, or to have it gently beaten with small leafy twigs. It is also common to apply a cloth, dipped in cold water, to the head or face, or to have cold water thrown on the head or some part of the body, from time to time, by means of a douche-tube, the water being applied either in an undivided stream, or in the form of a small partial shower bath. Having remained the requisite time, the bather descends from the upper benches, and after a short stay in this lower temperature he retires to another room 284 BATHING. heated with warm air, where, after being dried, he puts on a flannel dress, and lies down on a couch for some time. Frequently, previously to lying down, the patient drinks some warm fluid, and takes other steps to encourage perspiration. He then returns to the ante-room, where it is custom- ary to remain a short time after being dressed, in order that he may be somewhat cooled before going into the open air.* 2. The confined or solitary vapour bath is that in general use in this country. The distinctive character of this is that the patient is restrained from locomotion, being confined in a small close cell or tent of cloth, containing the vapour. This form of bath admits of three modifications: a. the head of the patient being included in the apparatus, so that respiration is restricted to the air in which the vapour is suspended ; b. the head, or at least the mouth, not being included in the apparatus, so that the patient breathes the common air of the apartment; c. the apparatus being so arranged as to admit of the patient breathing either the vapour of the bath or the external air at pleasure. The vapour bath, as generally used in this country, scarcely requires description. It consists essentially of a small frame of wood surrounded by a woollen or other cloth impervious to vapour, enclosing a space little more than sufficient to contain the body of the patient seated on a stool in the centre of it. The vapour is admitted at the lower part of the apparatus by means of a tube connected with a vessel of boiling water. The more common modification of the bath used in this country is that which permits the patient to breathe the air or vapour at pleasure, by excluding or including the head through an opening in the side of the covering. Fixed baths of this kind are now common at all our watering-places, and in most of the large towns in the kingdom ; and there are several varieties of the apparatus of a portable kind equally effective. The best of these are the modifications introduced by Captain Jekyll, Mr. Green, and Dr. Gibncy of Brighton.-(- General effects of the vapour bath. — As the principal effects produced by both the vapour and warm water bath depend, in a great measure, on the same cause, namely, the application of heat and moisture to the surface of the body, it is ob- viously unnecessary to enter on a detail of all the * Osann, in Encyclopiidisclies Worterbuch der Med. WissHiisch. Art. Bad. Band. iv. Berlin, 1H30. t Many substitutes for these more elaborate contriv- ances have been suggested, and may be extemporaneous- ly employed with sufficient effect when such are not at hand. A thick blanket or two thrown round a drying- screen, or other frame of wood, and placed over a steam- tube connected with a common kettle, answers the pur- pose very well. The common slipprr-hath may also be used for the saina purpose, the patient being guarded from the sides of the bath by a covering of flannel, and the mouth of the bath being closed by a blanket placed round the patient's neck; the steam being admitted through an opening in the lower part of the apparatus. Perhaps one of the simplest, least expensive, ami most J convenient forms of the portable vapour bath, consists of a large open wicknr basket, like that used by wool- staplers, reversed over the patient and covered with ' blankets, the patient heimr previously seated on a small stool or chair placed upon a piece of floor-cloth, near the chimney of the apartment The tube from a small port- able steam-boiler, placed on the common fire, is intro- duced along the floor. The basket is so constructed, with a sort of open door at one side, as to admit of the exclusion of the patient's head at pleasure. consequences resulting from the use of the vapour bath, as this would be to repeat, in a considerable degree, what has been already described. Our object will be sufficiently gained by stating, in this place, the chief differences which exist be- tween the operation of the vapour bath and the warm water bath. These have chiefly reference to the bath as a medium of communicating heat, and as influencing the functions of the skin and lungs. The difference in the heating power of different media was formerly referred to when treating of the water bath as a means of increasing the tem- perature of the body. It was there stated that the heating power was greatly influenced by the density of the medium, its capacity for caloric, its conducting powers, the relative fixedness of its particles, &c. Cxteris paribus, the more intense the degree in which these qualities exist in the medium, the greater is its heating power. The following are the highest temperatures at which the respective liquids could be borne by the hand of the same individual : spirits, 130° ; oil, 129° ; water, 123° ; mercury, 117°. (Phil. Trans, vol. lxv. p. 111.) As a general bath, water can hardly be borne at the temperature of 120° ; Rostan bore it with great inconvenience for half an hour, of the temperature of 115°. In the form of vapour, however, this fluid can be employed as a bath at much higher temperatures. The ordinary heat of the Russian or Oriental bagnio is from 120° to 140° ; and it is occasionally raised as high as . 180° or 190°. The same difference of results, as j to the relative heating power of water and watery ! vapour, was observed by Dr. Edwards, in his ! experiments on animals. He could never get j frogs to remain alive more than two minutes in ! water of the temperature of 104°, although the | head was not immersed ; while they survived the | same degree of heat in vapour (and breathing it) upwards of five hours. (Loc. cit. p. 374.) When conveyed by the still rarer medium of air, it is well known that heat can be sustained, without inconvenience, at degrees greatly exceeding the highest now mentioned. In the experiments per- formed in heated rooms by Drs. Fordyce, Blag- den, and Dobson, air of a temperature varying from 200° to 260° was borne for a considerable time with perfect impunity. A still higher tem- perature, viz. 270°, had been previously borne by some young women in France, as recorded by Tillet and Duhamel ; and yet greater heat has been sustained by others since that time. In respect of the heating power of watery va- pour, an important difference results from the circumstance of its being breathed or not by the patient. The application of the vapour to the lungs tends to increase the animal temperature, not merely by reason of the additional surface thus exposed to the influence of the heating me- dium, but because such application puts a stop to the cooling process of evaporation constantly going on from the lungs in a dry air. It is ex- tremely difficult to ascertain the exact ratio of the heating powers of water and of vapour in its two different forms of application. Judging, however, from the results of common practice in the differ- ent kinds of bathing, and from a pretty extensive examination of the observations and opinions of BATHING. 285 practical writers, we are disposed to place reliance on the following comparative view as containing as near an approximation to the truth as can be obtained on such a subject. For reasons of prac- tical convenience we retain the ordinary divisions and titles of the warm-water bath. WATER. V A HO 0 R. Not Brc»lhed. | Brea'hed Tepid Bath . . Warm Bath.. 850— 920 920— 9tW 980 _ iogo 96° — lOfiO 1 900 _ lOOO 10(io_]-joo lono — iino 1-200 —ItiOO | 110°— 130° Independently of its greater power of commu- nicating heat to the body, when extended to the pulmonary surface, the vapour bath, when so ap- plied, will necessarily exert a very different local influence than when its action is confined to the skin. This difference of effect must always be kept in view in prescribing the remedy in affec- tions of the chest, or in persons predisposed to these. There is little doubt that at the corresponding degrees of temperature, the vapour bath occasions a greater degree of cutaneous transudation than the water bath, a circumstance easily explained by the difference of the two media as physiologi- cal agents. We would, however, make one re- cular cases in which the one is to be preferred to the other. The vapour bath at the corresponding (not the same) degree of temperature must be considered as upon the whole more derivative to the surface, more diaphoretic, and probably less stimulating generally. It seems, however, to have a less soothing effect on the nervous system. This result, in some cases at least, is partly owing to the more constrained and to the upright posi- tion in which it is usually taken. The reclining posture used in the solitary water bath, where no muscular effort is required to keep the body in its position, gives it a decided superiority over the common vapour bath or large water-baths, in cases of great debility or severe disease. In such cases, however, by a particular contrivance, the vapour may be applied to the patient in bed. Most of the cases formerly noticed under the head of the warm bath are equally benefited by the vapour bath, and some seem more benefited by the latter. We shall only here refer to one of these, namely, the well known condition of the system which precedes many acute diseases, and which is familiarly known by the name of a chill, because it is usually produced by the appli- cation of cold. This state often exists for several I davs before the re-action of disease and fever su- mark here in reference to this point, as it is of i . , . . lL. /,, - i pervene. It is the usual precursor of acute catarrh practical importance, and this is, that a part of i r , , ... ., r . , \ ,,- • , • • ■• • .i or bronchitis, asthma, pneumonia, rheumatism, the additional perspiration experienced m the ,. u 3 . « , ,tl vapour bath often arises from the disproportionate degree of temperature employed. Much greater latitude is commonly permitted in regulating the heat of the vapour bath than of the water bath: and we know that the former is often used at temperatures corresponding with those of the hot bath, when it is intended to be used—as a warm bath. One of the causes of increased transuda- tion in the vapour bath arises from the greater accumulation of fluids in the cutaueous and su- perficial tissues, a necessary physical result of the greater rarity of the medium; and this circum- stance, moreover, constitutes the vapour bath a more powerful derivative, cxteris paribus, than the water bath.* It is particularly necessary in using the vapour bath to attend to the actual temperature as indi- cated by the thermometer; even more so than in the case of the water-bath; the gradual increase being less felt owing to the greater rarity of the medium. And the caution is still more requisite because, in using the vapour bath, the tempera- ture is gradually raised to the proper degree, after the patient is in the bath. Medical uses of the vapour bath.—Generally speaking, the solitary vapour bath in which the head is not included may be said to be applicable in the same cases as the warm water bath, and to be productive of similar results. An attentive consideration of the peculiarities of action of the two kinds above noticed will point out the parti- * It is, probably, in this circumstance of the relative amount of superficial compression in the two cases, that we are to rind an explanation of a phenomenon fre- quently experienced in the water bath, and very rarely in the vapour hath. We allude to that feeling of pre- cordial oppression on first entering the bath, which is so distressing to many persons, and which, indeed, occa- sionally renders this form of bathing impracticable ; the sudden retropulsion of the blood from the whole surface 9f the body upon the heart and lun^s giving rise to the feelings of distress alluded to. diarrhoea, or dysentery, &c.; in a word, of the numerous class of inflammatory diseases which derive their origin from cold. In most of these cases the vapour bath is a very effective remedy if administered at the proper time and in the proper manner. The most proper time is the earliest possible after the application of the mor- bific cause ; but the remedy may still be applied with benefit, although with much less effect, at any time previously to the actual establishment of the local inflammation. After this has taken I place, or is about to take place, the application of the bath will, in most cases, be more injurious than beneficial. In cases of the kind now under I consideration, the vapour bath, particularly if the vapour is breathed, appears to possess decided advantages over the common warm water bath. But although fully convinced of the admirable effects likely to result from this mode of treat- ment, we cannot consider it as a practice to be had recourse to at the discretion of patients, with- out medical sanction, as, like ail powerful reme- dies, it is capable of doing harm as well as good. Under proper regulation, we have little doubt that it will in many cases effectually check the morbid | process, which, if left to nature, must end in formal disease. The temperature in cases of this I kind should not be high. The object being to derive to the surface without exciting the circula- I tion, the application of the vapour should be ■ commenced at the lowest degree which is felt to be agreeable, as about 95°, and the temperature should be gradually and slowly raised, and should rarely exceed 106°. The more copious the per- spiration that can be excited at a moderate degree of heat, the more likely is the result to prove beneficial. § 6. Of the "Warm Air Batli. The temporary exposure of the naked body to the air of a common chamber has been termed 286 BATHING. the air-bath; and although it has not often been formally prescribed in disease, it has frequently been had recourse to as a means of relieving slight degrees of feverish restlessness. It was practised and recommended for this purpose by Franklin. The immersion of the body in air of which the temperature has been artificially raised, is a therapeutical mean of much greater power, and has been extensively used as such. This is what is termed the warm air bath. Like the vapour bath, it is of two kinds, according as the air is breathed or not breathed. Warm air cham- bers have been employed on a great scale, as luxuries, by persons in health, and especially by the ancient Romans. They are still occasionally used for medical purposes, but more frequently as appendages to vapour baths than as distinct baths. The heated air chamber has, however, formed a frequent medium for experimenters to ascertain the effects of high degrees of heat on the animal body. The experiments of Drs. For- dyce, Blagden, and Dobson, in England, of Dela- roche and Berger, in France, and of many others, undertaken with this view, were formerly noticed and are well known. We allude to them here, only for the purpose of again remarking, that owing to the great rarity of the medium and to the cooling effects of the evaporation produced by the dry air, a very high degree of temperature can be sustained in air with little inconvenience. Much lower temperatures, however, than were borne in these experiments, suffice to produce all the stimulating effects of the ordinary hot bath, whether of vapour or water. In the experiments of M. Berger and Delaroche in air of a tempera- ture varying from 150° to 190°, the following effects are noticed: — A considerable degree of smarting was perceived in different parts of the surface, particularly in the eyes, nose, and nip- ples; the superficial veins became universally dilated; the surface, at first burning hot, was soon covered with general and very copious per- spiration. The temperature of the body was raised several degrees; the pulse rose to 160; the respiration became anxious; and headach, vertigo, and other symptoms of cerebral disorder took place. The above temperatures represent those which correspond with the higher degrees of the hot water bath. Much lower, therefore, are employed when we wish to produce effects corresponding to those of the warm water bath. The warm air bath is now most commonly used as a solitary bath, the patient not breathing the heated air. By much the most convenient form of the apparatus is that introduced a good many years since by Dr. Gower, under the name >f the sudatorium* This consists merely of a semi-cylindrical frame-work of wicker, laid over the patient in bed, and covered with blankets. By means of a metallic tube communicating with the end of the frame, a stream of air, heated by a lamp placed at the extremity of the tube, is directed into the hollow space formed round the patient. The speedy and almost certain effect of this bath is to produce copious general perspira- tion. It may be used at different temperatures, * See his little work eutitled " Auxiliaries to Medi- cine." Loudon, 1819. and be so regulated as to correspond with the divisions adopted in the case of the water and vapour baths. Although, as we have stated, a much greater degree of heat is required in air than in vapour to produce either the elevation of the animal temperature, or the stimulating effects on the system, still it is found, by experience, that a moderate degree of heat is alone necessary to excite copious perspiration. No doubt the sudatory effect is greatly promoted by the rarity of the medium applied to the surface. Dr. Gower informs us that he found the most profuse sweating take place when the air was only of the temperature of 85°, and he adds that he " had reason to believe that at a much higher degree the effect would be rather frustrated than in- creased, owing to the ardent heat which the patient feels and complains of, without obtaining the relief which sweating invariably produces." Our own experience with this apparatus does not quite correspond with this statement of Dr. Gower. We have, however, found that very copious perspiration may be excited by a tem- perature not greatly above this, viz., from 90° to 100°; and we are of opinion that even when we use this bath more with the view to stimulate the surface than to excite perspiration, it will seldom be requisite to elevate the temperature beyond 120°, or at most 130°.f The warm air bath is most analogous in its ope- ration to the vapour bath ; yet it is considerably different from it It seems to possess all its stimu- lating qualities without its relaxing and soothing effects. It is, therefore, a much more exciting ap- plication at the corresponding temperatures. It appears to be more powerfully derivative to the skin than any other bath, and more certainly pro- ductive of perspiration within a short period. There are three classes of cases in which the warm air bath seems to be particularly indicated : —1. in chronic rheumatism and other pains and stiffness, as of the joints ; 2. in morbid states of the skin, more particularly in dry scaly eruptions; 3. in acute diseases marked by great exhaustion and retrocession of blood from the superficial parts of the body, as in certain forms of fever, and in the malignant or spasmodic cholera. In the last- mentioned diseases, (which alone we shall notice in this place,) and in others of the same class, the warm air bath, employed on Dr. Gower's plan, has great advantages over all other kinds of baths, inasmuch as its effects on the system are as pow- erful, while its application can be made without trouble or inconvenience, and without any risk of yet farther exhausting the patient. This bath was occasionally used by the late Dr. Armstrong in that form of fever which he termed congestive. The following brief extract from his lectures will point out the cases in which he recom- mended it, and the fortunate results which he ob- t The warm air bath, and its great power in inducing perspiration, were well known to the older practitioners. Aliud genus balneorum est (says Hoffmann' qua? aiidiimt vaporosa sive Laconica. In his vapores, sive stcci caliii er accenso vtw sp/ntu halantes, sibe cali.ti humidi ex necoctis nernarum cum vino vel aqua surgentes, imme. mate ad umvRrsum corpus vel ad certas duntnxat ipsiiis partes, a.nnutuntur. Est autein calidorum ejusmodi hit- iitiium maxima vis ad eliciendum sudorem, tubulossuh- cutaneos aperiendos," Scc.-F. Hoffmann, Op. Om. torn. i. BATHING. —BERIBERI. 287 tained from its employment. « The whole surface is chilly ; the blood has retreated from the surface, and has been accumulated in some internal organ, where it undergoes almost a complete stagnation, or at least produces a complete interruption of the venous circulation. A derangement of the func- tions of that part is the result and, if that part be important, of the functions of the whole body. The use of the hot air bath is to rouse the ener- gies of the system; and in some of these cases the patient is raised, as by the touch of a magic wand, from weakness to strength by its applica- tion." (Dr. Armstrong's Lectures. Lancet, vol. v. p. 74.) We have much pleasure in laying before our readers the following notice on the same subject, with which we have been favoured by Dr. Twee- die : — " It sometimes happens that the febrile poison is so intense, and the living power so depressed by it, that, the subsequent efforts of the system to bring on re-action being ineffectual, the patient is suddenly placed in great danger, and often dies in a few hours after the first appearance of the symp- toms. Under these circumstances the surface feels cold and damp, more especially on those parts which are at a distance from the centre of the cir- culation ; the pulse is feeble and compressible; the functions of the brain are disturbed; the breathing is anxious and hurried, and the lips are livid. All these symptoms depend on the pecu- liar operation of the febrile poison on the nervous system, and on the irregular distribution of blood consequent to this. This fluid, probably changed also in its properties, recedes from the surface, and accumulates in the internal organs. In other in- stances, sudden collapse supervenes in the more advanced stages of fever, and similar symptoms make their appearance. In such embarrassing circumstances, much judgment is requisite to res- cue the individual from the danger in which he is plunged. Some writers have recommended blood- letting with the view of relieving the congestion which is supposed to have taken place in the internal organs. This treatment may, in some instances, have been beneficial, though it appears to me that it can only be adopted when the circu- lation, though oppressed, is still carried on with some degree of vigour ; because, should blood be abstracted when the heart's action is weak, fatal syncope mav he induced. It should be remem- bered that, though the heart's action is, in such cases, oppressed by the accumulation of blood which it is unable to propel, this want of power in the heart is primarily induced by the peculiar action of the febrile poison on the whole nervous system. In this debility the hpart, of course, par- ticipates. In this state of things, more benefit certainly results from the exhibition of diffusible stimulants, while at the same time efforts are made to determine the blood to the surface by the application of the warm air bath. In cases of collapse coming on in the later stages of fever, bleeding is out of the question: the patient, already exhausted, is thrown into a species of con- tinued syncope ; and from this he is to be roused by the cautious administration of stimulants, aid the application of the hot air bath. The exhibi- tion of stimulants is only to be continued white the pulse continues feeble and soft; they are to be immediately withdrawn, or given at more dis- tant intervals, when re-action has taken place." The pathological state in the early stage of ma- lignant or Indian cholera is very analogous to that in congestive fever; and the indications of treat- ment seem precisely similar. In such cases the warm air bath, speedily raised to a high tempera- ture, offers one of the best means of fulfilling these indications; and we are happy to observe that very general preparations are making to give it a trial in the disease that has just (Oct. 1831) broken out at Sunderland. [This remedy was extensively used in the cho- lera hospitals in different countries, and was as serviceable, perhaps, as any other external agent] This would be the proper place to notice the other forms of baths in which the heated air is combined with sulphureous and other dry vapours; but the consideration of these, as also of the me- dicated humid vapour baths, particularly the chlo- rine bath, must be postponed to another occasion. At present we must content ourselves with refer- ring to the works of MM. Gales and Rapou, and to the publications of Dr. Wallace, of Dublin. John Forbes. BERIBERI. The disease usually denomi- nated beriberi was, we believe, first scientifically described by Dr. Rogers, who published a thesis on the subject in 1808, at Edinburgh. He deno- minates it hydrops asthmaticus, a term which conveys an imperfect notion of the pathology of the disease, a paralytic affection of the lower ex- tremities being, perhaps, a more constant symptom of beriberi than dyspnoea and dropsical effusion. Dr. Mason Good calls it synclonus beriberia, and gives the following definition :—" Spasmodic ri- gidity of the lower limbs, impeding locomotion ; often shooting to the chest, and obstructing the perspiration and the voice -. trembling and painful stupors of the extremities; general oedematous intumescence." This definition Ls tolerably accu- rate ; but in his description he confounds a chro- nic paralytic affection (barbiers) with the acute disease now under consideration. The word beri is stated by Staff-Surgeon Mar- shall, in his Notes on Ceylon, to imply, in the Singhalese language, weakness or inability; in fact, we may consider it as a generic name, agree- ing with our word disease. The repetition of the term beri conveys an idea of the greater intensity or degree of debility. Beriberi is characterized by oppressed breathing, general oedema, paralytic weakness, and numbness of the lower extremities. The attack is sometimes very sudden, but more commonly the patient complains for some days previously of languor, weakness and inability, or unwillingness for motion. The first appearances are numbness and stiffness of the extremities, with oedematous swelling of the feet and legs. These symptoms often show themselves simultaneously. The patient, experiences great weakness and breathlcssness, especially on motion ; the anasarca extends upwards over the body, accompanied with a peculiar feelina: of numbness, with fulness, and a sense of weight and oppression in the scrobicu- lus cordis ; the face becomes swollen and bloated, and the lips are pale ; in the advanced stage they 288 BERIBERI. are blue and livid : dyspnoea is always present in a greater or less degree, and is much increased by exertion; the pulse is usually quick, small, and hard, sometimes little affected, but as the disease advances, becoming irregular and intermittent; the stomach is often very irritable, especially in the advanced stages of the disease; the bowels are constipated, the urine is high-coloured and scanty, and sometimes suppressed. As the disease advances, the dyspnoea and anxiety become most distressing ; the sleep is unsound and interrupted; the patient complains of violent palpitation, and experiences great uneasiness, especially in a recum- bent position ; the feeling of weight at the prae- cordia increases, and spasms of the muscles of the chest and abdomen take place : vomiting becomes incessant, the pulse sinks, the lips and counte- nance assume a livid hue, and the patient is car- ried off in a state of suffocation. In cases where debility, oppression, anxiety, and dyspnoea are ex- tremely severe from the beginning, the patient sometimes dies in a space of time varying from six to thirty hours. When the symptoms are less violent, the disease may continue for three weeks or a month, or, as frequently happens, the patient experiences a number of relapses, and is at last carried off suddenly, sometimes after the dropsical symptoms have subsided, and he seems to be con- valescent Mr. Holloway had two patients, who died without appearing to awaken from a state of sleep. In general, however, death is immediately preceded by great agony. The writer of this article had an opportunity of witnessing the phenomena attending this dis- ease at Trincomalee, in the Island of Ceylon, where it prevailed in 1815. In some of the cases that came under his notice, the external or ana- sarcous symptoms were apparently unimportant, although death was the result. Some of the pa- tients expired who appeared to be recovering, and who stated, shortly before death, that they were better than they had been for several days. The dropsical effusion did not by any means appear to be the immediate cause of death, and Dr. Christie states that some of his patients died who had no decided anasarcous symptoms ; the face was, how- ever, bloated and leucophlegmatic. Beriberi was very prevalent in various parts of Ceylon from 1795 to 1803. In the former year two hundred Europeans died in Trincomalee, chiefly from this disease. (Rogers de Hydrope Asthniatico.) It also prevailed at Colombo, both among European and native troops. During the Kandyan war in 1808, its ravages were severely felt. Among Europeans, those engaged in certain occupations, such as tailors, smiths, &c, were especially liable to beriberi; while commissioned officers, women, and children, were generallv exempted from it. This disease appeared in a comparatively mild form in Kandy, in 1820-1, and ever since it has been little known in Ceylon. Beriberi prevailed among the troops in the Carnatic in 1782-3.* Mr. Hamilton says, " it is principally, if not en- tirely confined to Ceylon, to the Malabar Coast, and to that tract of country reaching from Madras as far north as Ganjam, in no part extending in- * Med. Commentaries, vol. x. and Trans, of the Medico- I'nirurgical Society of Edinburgh, vol. ii. 1826. land more than 40 miles. It is most prevalent during the decline of one monsoon and setting-in of another, when the atmosphere is loaded with damp, raw, cold vapours, and the vicissitudes of temperature are greater than at any other season of the year; and the instances are comparatively rare where it has been found to occur at a distance from the sea exceeding sixty or seventy miles." It may be remarked, however, that Kandy, where the disease was particularly severe, is at a much greater distance from the sea. At Trincomalee it was observed that the most severe cases oc- curred during the change from wet to dry weather, where a strong and hot land-wind prevailed; whereas at Palitoopane it appeared in 1814, while the weather was remarkably dry.-j- Dr. Christie has remarked, that a residence of some months at a station where the disease pre- vails seem essential to its production. Dr. Rogers never saw it attack an individual who had been less than six months in Ceylon. Beriberi occa- sionally occurs at sea, especially among Lascars (Indian seamen) on the outward-bound voyage. Dr. Hunter has given a particular account of the probable causes, and of the treatment employed in several of the East-India Company's stations where it prevailed. The remote as well as the proximate causes of this disease are extremely obscure. Drs. Christie and Rogers, and several other medical gentlemen who observed it in Ceylon, considered it a disease of debility, arising from a want of stimulating and nourishing diet, impure air, and exposure to a moist and marshy atmosphere while the frame is debilitated by residence in an unhealthy station. How far these circumstances contributed to pre- dispose the system to beriberi, it is difficult to say. Mr. Marshall (Notes on the Med. Topography of the Interior of Ceylon) remarks that "during the insurrection in Kandy (1815), the troops and public followers were greatly exposed to variable weather, privation in regard to food, and other causes of physical and mental exhaustion. For- tunately, however, beriberi did not supervene." Mr. Colquhoun and others who adopted every available precaution with respect to food and clothing, were mortified to find that the disease did not seem to be materially checked by their prophylactic measures. No particular cause could be assigned for its appearance in the 19th regi- ment, at Trincomalee, in 1815. There is extremely little accurate information before the public in regard to the organic changes which occur in this disease. The skin is usually pale and colourless ; and Dr. Christie observes that a remarkable degree of obesity exists, even after a long continuance of the disease. The cellular membrane in general is found infiltrated with serum ; and Dr. Rogers states that he dis- covered a small quantity of fluid effused between the brain and its membranes, as also in the cerebral cavities. Mr. Hamilton says that he ob- served general vascularity in the brain, effusion of fluid into the ventricles, with appearances of congestion in the medulla spinalis. t Ridley, Account of an Endemic Disease of Ceylon. Dublin Hos. Keports, vol. ii. p. <&7. and Essay on the Diseases incident to Indian Seamen on, long Voyage-'. by W. Hunter, Calcutta, 1804. BERIBERI. 289 A greater or less quantity of serous fluid is usually found in the cavities of the pleura and pericardium. Dr. Rogers states that it varied from a few ounces to two pounds in the former, and in the latter from two to twelve ounces. In a case related by Mr. Marshall, the fluid in the pericardium amounted to four ounces, Mr. Hamilton describes a case where " a large quantity of fluid was effused into the cavities of the pleura, but none into the pericardium, though on this membrane, both externally and internally, there existed evident marks of inflammation." The lungs are gorged with blood and watery fluid. In the abdomen a quantity of fluid, varying from two to three pounds, is commonly found. The liver is invariably described as being unusually large and very dark-coloured. Mr. Marshall states that in his case, on removing it from the body, a great quantity of dark-coloured blood flowed from the large vessels, and that it then became reduced in size and natural in colour. The whole sub- stance of this viscus is commonly gorged with blood. Several other traces of disease, such as inflam- mation of the diaphragm, intestines, &c, are men- tioned by authors, but so loosely, that little reliance can be placed on their description. Diagnosis. — It is scarcely necessary to enter much into the diagnosis of this disease. The paralytic symptoms, together with the dyspnoea and dropsical effusion, would appear sufficient to distinguish it from other diseases. The mal d'es- tomac and cachexia Africana, which have often been confounded with beriberi, are totally dif- ferent diseases. The real nature or pathology of this disease is as obscure as its origin. We know nothing satis- factory respecting the origin of the paralytic symptoms, nor regarding the immediate cause of death, where there is little or no dropsical effu- sion. Accurate observation and more extensive experience are wanting, to enable us to arrive at any thing like a satisfactory conclusion on the subject From what we have seen of beriberi, and from our subsequent experience in other dis- eases, we are strongly inclined to consider the dropsical affection as the result of inflammation. In fact, it seems to be one of the numerous modi- fications of acute dropsy that affect the cellular membrane generally, but more particularly the cellular texture of the lungs, whereby a condition similar to that described by Laennec, under the name of oedema of the lungs, is produced. We have often been struck with the resemblance in the countenance and general appearance in pa- tients affected with beriberi, and in the suffocative disease, with oedematous effusion, which attacks children after measles or hooping-cough. In no disease with which we are acquainted, is internal congestion so strongly marked as in beri- beri. How far this congestion may be the origin of the paralytic symptoms is a difficult question. Mr. Hamilton attributes them to congestion of blood in the brain and spinal marrow. Treatment.—The method of treatment pur- sued by Dr. Christie, and recommended by him to the medical officers in Ceylon during the pre- valence of beriberi in that island was in corre- spondence with the views then entertained of the Vol. I. — 37 z nature of the disease. The patients were at once put on a course of calomel and squills ; saline and antimonial medicines were also given, and the strength supported by cordial liquors, gene- rally gin-punch : the sheet-anchor, however, as Dr. C. forcibly expresses it, was mercury, given so as to induce ptyalism. He adds that, " by these medicines the symptoms in the milder cases are very often removed in the course of a few days, except the numbness of the extremities, which generally remains longer than the rest." The pediluvium and stimulant liniments to the extremities were then ordered, and the patients were put upon a tonic plan of bark and wine, or porter, which was continued for some time after all the symptoms had disappeared. In the more severe cases, where the dyspnoea, vomiting, spasms, or other symptoms were violent, it was necessary to apply blisters to the breast, to make use of fomentations and the hot bath, and to ex- hibit the strongest cordials and anti-spasmodics, such as brandy, and particularly laudanum and vitriolic ether. " By these means I have," says Dr. Christie, " in most instances been enabled to relieve the dyspnoea and other urgent symptoms, and procure time for the exhibition of the medi- cines mentioned above, which it is sometimes necessary to use for several weeks." Digitalis was tried, but without any decided effect. Mr. Colquhoun also trusted to mercury in this disease; but he remarks that salivation did not avert the fatal termination, for the patients who died in hospital were frequently in a state of ptyalism. During the period in which the writer of this article had an opportunity of witnessing beriberi at Trincomalee, the method of treatment laid down by Dr. Christie was strictly pursued, but with little cause of congratulation as to its suc- cess. The patients frequently sank while under the influence of mercury; and he has often regretted that the dyspnoea, discoloration of the countenance, &c, did not lead to a different mode of treatment. Mr. Hamilton treated the first two cases which came under his charge according to Dr. Christie's plan, and both proved fatal. Dr. Hunter says that in one of the outward-bound ships venesec- tion was had recourse to, but without any effect, either of accelerating or retarding the disease. Dr. Rogers, in his Dissertation already referred to, has the following words : " Quin et ad phle- botomiam tandem cursum ejus funestum celerius absolvit" Increased experience appears to have induced Dr. R. to alter his plan of treatment, for we find from Mr. Hamilton's statement, that in 1822 he approved of bloodletting, and success- fully employed it in two cases. Mr. Marshall remarks that in 1820 many cases of anasarca occurred among the European troops in Kandy : the first cases were comparatively mild, and a considerable period elapsed before the well-marked and pathognomonic symptoms of beriberi appeared. Brisk cathartics and con- finement to bed generally reduced the swellings and relieved the numbness in a few days. In a case where the chest was severely affected, great and speedy relief was obtained by copious and repeated bleeding. The depleting method of 290 BERIBERI—BLOOD, (DETERMINATION OF) treatment was followed by Dr. Paterson, in the hospital of the 45th regiment, then under the superintendence of Mr. Marshall, with decided advantage. Mr. Hamilton, as has been already stated, having treated two cases unsuccessfully, was led, from the morbid appearances, to adopt other remedial means. In the next patient who came under his care, thirty ounces of blood were drawn, pleno rivo, from the arm. The blood was buffed, and the operation was attended with great relief; but as the symptoms returned, venesection was repeated to the amount of thirty-five ounces, with good effect Mercury was then had recourse to, with laudanum, the vapour-bath, inunctions of mercurial ointment, with purgative doses of calomel and gamboge till the cure was completed. A similar mode of treatment was pursued in two other cases, in one of which blood was drawn, to the extent of sixty-five ounces, at three different limes in the course of thirty hours. According to the views supported in the former part of this paper, it will be seen that our mode of treatment would be in accordance with that pursued by Mr. Marshall and Mr. Hamilton. The quantity of blood to be drawn must of course de- pend on the state of the disease, and the constitu- tion of the patient; but we should scarcely feel inclined to recommend the large and successive bleedings employed by Mr. Hamilton. If the patient be placed in an upright position, and the blood be drawn in a full stream, a smaller quan- tity will produce a more decided effect on the system, with less risk of producing subsequent debility. Free purging by calomel and gamboge, while the secretions of the mucous membrane and kidneys are stimulated by cream-of-tartar, squills, &c, with the use of the vapour or warm bath, and stimulating liniments to the limbs and spine, and blisters to the chest when the symptoms re- quire it, will prove useful assistants in the treat- ment of beriberi. We may conclude with Mr. Marshall's remark, that a more extended clinical experience is still necessary, before a due estimate can be made of the true efficacy of the depletory means of cure. T <-, J. Scott. BLISTERING. (See Counter-irritation and Derivatiox.) BLOOD, (DETERMINATION OF.)—This term is used to denote an afflux of blood to a par- ticular part, impelled by increased arterial action. When such afflux exists without any obvious increase of impelling power, it is denominated congestion. Both may co-exist; that is, conges- tion may first take place, and, on vascular action becoming excited, determination may ensue, in- creasing still further the congestion, and super- adding those lesions which determination more especially occasions; or congestion may be pro- duced by determination, and may continue after this has subsided. Congestion is more or less a passive condition ; determination is always active. On determina- tion subsiding, congestion may yield to the sana- tive powers of the constitution, unaided by medi- cine ; or it may continue, and require special means to be resorted to for its removal. When congestion takes place in any part, its origin must be ascribed to some weakness of the vessels of the part, causing them to yield to the ordinary force of circulation -, in determination, vessels which would resist the ordinary force of vascular impulse may become over-distended by increase of momentum ; yet here there must be some relative weakness to cause them to give way. The relative facility of yielding to distension, thence arising, whether natural or acquired, may influence the locality of the determination; or this may be directed by various sympathies and nervous connexions, and also by some peculiar property of the stimulus which produces the vas- cular excitement. Some determinations are solely attributable to nervous sympathy, as those which occur in health under mental emotion. In blush- ing, for instance, there is obvious determination of blood to the cheeks; nay, when intense, to the whole neck and breast. Similar instances might be adduced, but it is needless to advert to them, morbid determination being the condition under consideration. It is, perhaps, from the influence of nerves in giving direction to local determina- tion, that certain stimulants determine blood more particularly to certain organs, some causing blood to flow more particularly to the brain, while others tend to induce vascular fulness in the hver or in other parts. Determination admits of being inferred from the symptoms which denote it, these varying ac- cording to its seat, and to the functions of the part affected ; the fact of its occurrence is amply verified by necroscopic examination when oppor- tunity for this is afforded. As determination may ensue upon congestions, so may it be followed by, or pass into, inflamma- tion, of which indeed it seems to be an essential constituent But as congestion does not necessa- rily produce determination, neither does determi- nation pass necessarily into inflammation. Such determination, though an advance towards inflam- mation, and prone to pass into it, may yet exist so as to constitute formidable disease, and thus continue for an indefinite time without inflamma- tion ensuing. Congestion of blood, kept up by determination, may take place in the brain, lungs, liver, or any other organ, without evincing the peculiar phenomena of inflammation, and may, in each, cause appropriate disturbance of function to a formidable extent. When such cases are treated as subordinate degrees of inflammation they yield readily, and to practice less active than inflammation would require ; but when from the absence of purely inflammatory symptoms, they are referred to debility or some unexplained ner- vous derangement, and are in consequence treat- ed with stimulants, they rather become aroused into inflammatory action, which perhaps is in such cases the happier result, as they are then treated aright; or they lead insidiously to disor- ganisation of structure, thus laying the founda- tion of some of the most irremediable of human diseases; for though medicine can do much to correct functional disturbance, and can to a cer- tain extent promote even restoration of structure where the organic change has been slight, it can- not supply new organs, nor give to a scirrhous and disorganised mass the efficient energies of a healthy viscus. On which account the study of determinations, and of the causes both local and BLOOD, (MORBID STATES OF) 291 institutional from which they arise, is of the highest importance, as a just conception of their nature and tendencies may enable the practitioner to avert, by very gentle means, lesions of the frame which, if suffered to advance to a certain extent, the utmost efforts of his art may be una- able to remedy. In this instance the maxim, " principiis obsta" cannot be too forcibly incul- cated. The special determinations, however, be- long not to this place ; they either constitute, or are connected with, special diseases; under each of which they will of course be found respectively noticed. „ „ Edward Barlow. BLOOD, (MORBID STATES OF.) —The term blood needs no definition. Every one knows that the blood is that fluid which is circulated chiefly by the powers of the heart and arteries, over the whole animal frame, of every part of which it constitutes an essential ingredient. The blood must be first viewed as arterial and venous. The former, of a florid red hue, flows from the extreme parts of the lungs to the extreme parts of the system; the latter returns from the system to the lungs. The blood itself is only one degree more essential to life than its arterial character. In all the high orders of animals of adult age, life ceases in a few minutes after the blood is pre- vented from assuming the arterial character in the lungs, by cutting off the contact of the atmo- spheric air. In proportion as the individual is younger, however, it bears the exclusion of the atmospheric air better, and the detraction of blood worse. The blood, as it flows along or from the large vessels, has the appearance of a homogene- ous fluid, of a red colour, of a rather viscid con- sistency, having a peculiar flesh-like odour, and an unctuous feel. Seen flowing along the capil- lary vessels, or placed upon a portion of glass, by the aid of the microscope, the blood presents the appearance of globules floating in a serous fluid. Stagnant, or removed from its vessels, the blood soon loses its homogeneous character, and divides into two portions, of which one is more solid, and termed the cruor or crassamentum, the other more fluid, yellowish, and transparent, and denominated the serum. We purpose dividing the subsequent remarks, to which we shall endeavour to give a practical character, into two sections : the first will treat of the natural, the second of the morbid state of the blood. There are several modes of analysis of the blood : the first is chemical, and consists in deter- mining the secondary and ultimate elements into which the blood may be divided; the second may be designated the physiological, and would con- sist in determining the elements of the blood as it exists in the different parts of the arterial and venous systems, under various circumstances; the last, which will alone occupy us in this place, mav be viewed as the clinical, and consists of ob- servations on the blood and its several parts, as it undergoes its spontaneous changes on being drawn from an artery or vein. We have desig- nated this kind of analysis clinical, because it is principally this which daily becomes an object of greater interest and importance. We, however, by no means wish to exclude the other modes of analysis from clinical inquiry. The first part of this clinical analysis of the blood is, as we have stated, into cruor and serum. On a minuter examination, it is found that the cruor consists of two different matters, very easily separable from each other, by immersion or wash- ing in water. The more solid part of the cruor is, by this simple process, deprived of its colour- ing principle, becomes whitish, and appears fibrous: it is designated fibrine. The colouring matter is more or less dissolved in the water : it has been de- nominated hxmatosine, (from a'lpa, aiparos, blood,) to denote its constituting a peculiar and essential part of the circulating fluid. Hsematosine is not a simple substance. It is composed, according to Berzelius, of .500 of oxide of iron, .750 of sub- sulphate of iron, .200 of magnesia, .200 of chalk, and .105 of carbonic acid. The serum is, in its turn, susceptible of a simple analysis. Heat, or alcohol, induces the coagulation and deposit of one of its principal constituent parts; this is termed albumen. One of the first occupations of the medical stu- dent should be, to become familiar by actual ex- periment with these, different substances. The experiment itself is one of the simplest and most instructive. We learn by it at once the partial solubility of hxmatosine, the insolubility of fibrine, the solubility of albumen in cold water, and its insolubility in hot. The texture of the cruor, the quantity, appa- rent and real, of the serum, vary; the serum is sometimes slightly opaque; the hsematosine is occasionally partly precipitated to the bottom of the vessel in which the blood is received. But these are probably morbid conditions, and will be considered in the ensuing section. Besides the albumen, the serum contains vari- ous substances, of which the following are the enumeration and proportions according to Berze- lius : water .905, albumen .080, chloruret of po- tassium and sodium .006, lactate of soda united to an animal matter .004, carbonate of soda, phos- phate of soda, with animal matter .004. Doubt- less each of these substances has an important influence in the animal economy. The little we know of their influence should only excite us to further inquiry in regard to these substances. Besides these matters, according to the analy- sis of Berzelius, other substances have been dis- covered in the blood : as carbonic acid, substances severally resembling mucus, oil, brain, the colour- ing matter of bile, and of the urine and urea. For more minute details we must refer to the various systems of chemistry. The clinical analy- sis of the blood must almost inevitably be con- fined to the more obvious results of observation, although we dare not exclude experiment alto- gether. Arterial blood is less abundant than venous. It separates more promptly into cruor and serum. It contains less albumen, and is at once less vis- cous and less serous. Dr. J. Davy found that it possesses less specific gravity. It is said to have less capacity for heat. It has more of the pecu- liar odour of blood. One of the most interesting questions in this inquiry is that which relates to the differences in 292 BLOOD, (MORBID STATES OF) the blood in the first and later periods of life. It is a singular fact that the globules of the blood in the foetus are larger than those of its mother. According to Prevost and Dumas, they are of double the magnitude of those of a man of adult age. According to Fourcroy and Dr. Davy, the albumen is more abundant, and the fibrine less firm in infants than in adult age. It is said that differences are perceptible in the blood of youth and old age, and of the two sexes. M. Barruel has recently occupied himself with the latter subject. § 1. It may be safely alleged that there is no external agent which may not, under extraordi- nary circumstances, become the cause of disease : it may also be alleged that there is no internal part, whether it be solid or fluid, in which the seeds of disease may not be sown. The blood, of all the fluid parts of the animal economy, seems, from its complicated formation (may we not say structure ?) to be most liable to morbid changes. The older physicians observed the dissolved state of the blood, as it was termed, in some cases of fever and scorbutus, and the sin- gular appearance called buff upon the crassamen- tum in certain cases of inflammation. Had they not unfortunately deviated from the course of pure observation, we should now have possessed a series of facts of extreme value. But from the moment that certain unfounded chemical and humoral notions began to prevail, and physi- cians to speak of the acidity, the alkalinity, the acrid, the putrescent state of the blood, and of chyle, of milk, of pus, of bile in the blood, from mere hypothesis, observation was at an end. The error being detected, the whole humoral pathology fell into disgrace, and physicians, pass- ing from one extreme of opinion to another, be- came pure solidists, as they were termed, whilst obvious and well ascertained facts became neg- lected. But now that all exclusive views in physic have ceased, and that every organ, every texture, every fluid is subjected to careful observation, there is no doubt that many morbid changes will be discovered, not only in the blood, but in the other animal fluids, whether such as are provided for the nutrition, or such as are separated for the purification of the system. Indeed if any of these be morbidly affected, the blood itself must suffer by the addition of what is imperfect, or by the retention of what should be discharged. It is in this manner that impure air, and impure diet, and defective excretions of the faeces, urine, or per- spirable matter, act in impairing the condition of the blood. The first of the morbid changes which take place in the blood relates to its quantity. This may be excessive or deficient: the former state is denominated plethora, and will be treated of under that head; the latter condition constitutes the state of ansemia, of which an account has already been given. (See Plethora, Anjsmia.) The next changes in the blood relate to excess or deficiency in one or more of its constituent parts. The cruor, the serum, the colouring mat- ter or hsematosine, may each be too abundant or deficient The same observation may be made in regard to the constituent parts of the blood j viewed under a different aspect: the fibrine, the albumen, the saline ingredients may severally be augmented or diminished. | Other changes consist in the different manner in which the spontaneous separation of the cruor and serum takes place : sometimes this separation is very distinct; the cruor is firm and cupped, whilst the serum is fully pressed out and appears I copious : in other cases the cruor is large and loose in its texture, involving a considerable quantity of serum, the portion pressed out being small: in a third case, in which the albumen ap- | pears to be in excess, this substance is separated, mingled with fibrine, and attached to the upper surface of the firm and cupped cruor, forming what is designated the bufty coat: in a fourth case the cruor is small, distinct in form, yet neither firm nor cupped, and floats in a serum of greater viscidity than usual. A further series of changes consists in the de- fective coagulation of the blood, which remains more or less sanious, and is of various colours. In other instances the blood appears to be de- ficient in hsematosine as well as in fibrine and albumen. It is more or less deprived of colour and viscidity. Its cruor is of a salmon colour. Dropped upon white linen, it scarcely affords a tinge. This occurs especially in cases of pro- tracted hemorrhage, and in chlorosis. Besides the changes in the proportion of its different constituent parts, the blood frequently contains matter foreign to its healthy constitution, as pus, the encephaloid substance, entozoa, cal- culi. At other times the blood itself undergoes | other changes, becoming gruinous, sanious, &c. That other changes still are induced in the blood, is proved by experiment. The morbid blood injected into the veins or cellular membrane of a healthy animal, immediately induces morbid or fatal effects. M. Gendrin introduced an ounce of the blood of a man affected with fever with gangrenous pustules, into the cellular membrane of the groin of a cat Various symptoms followed, and the animal died in little more than six hours. The same effect was produced on injecting blood of the same patient into the crural vein of a dog. Similar results followed the similar injection of the blood of a patient affected with variola. From these and similar facts it becomes quite obvious that the blood itself is morbidly affected in various diseases, as the worst forms of fever, variola, &c. The blood may become morbid, not only from a deficient freshness of the air, and a deficient quantity of food, but from deleterious matters in- corporated with the air or food. Contagious mi- asmata, malaria, may float in the atmosphere and corrupt the blood. Poisonous substances may be conveyed into the circulating system, more or less promptly, by means of the diet: many interesting facts of this kind are on record; but none is more so than the well-known influence of salt provisions iu inducing scorbutus, and of the ergot in indu- cing a tendency to gangrene of the extremities. The nervous system has also a direct influence upon the blood. In experiments in which the eighth pair of nerves has been divided, it is said that the venous blood is prevented from being changed into arterial (Dupuytren) ; that the blood BLOOD, (MORBID STATES OF) 293 even coagulates, and the fibrine and hromatosine separate in the larger pulmonary arteries and veins (Mayer) ; and that arterial blood drawn from the carotid was deprived of a portion of its fibrine (Dupuy). The same experiment, performed by M. Dupuy upon a horse, is said to have led to a dissolved state of the blood. Being injected into the veins of another horse, this blood is said to have induced gangrene. Who, after reading these facts, will doubt that the humoral pathology has a solid basis in nature ? It can, however, only be erected by observation and experiment, conducted with extensive views. Every inroad, every egress, every source of modi- fication, physical or physiological, must be care- fully taken into consideration in such an investi- gation. § 2. We shall now proceed to enumerate the various diseases in which changes in the blood are obvious enough to be placed beyond a doubt, yielding facts which may be added to science. The first disease we shall mention is fever. There can be no doubt that the blood is variously affected in various kinds of fever. There can be little doubt that this affection of the blood is some- times the primary affection. If this fact be esta- blished, the dispute whether fever be ever idiopa- thic, that is, independent of local disease, will be at an end. Much information respecting the condition of blood in fever may be acquired from some of the more ancient authors, especially of what may be termed the observant sect, as Sydenham, Huxham, &c. The latter author describes the appearances of the blood of malignant fever thus : " The era- sis of the blood is not sufficiently firm, too attenu- ated ; the serum blackish or tinctured with red." (On the Air and Epidemics, vol. ii. p. 68.) In speaking of what he designates peripneumonic fevers, or in modern language, of fever complicated with pulmonary affection, he says, " The blood of such persons is always found too dissolved, although it is generally florid and specious, and for a long time preserves its serum ; examine it at another time, and you will find the crassamentum livid and exceedingly dissolved, and swimming in a great deal of tawny, turbid, greenish, or reddish serum; again, at another time it is almost black and sanious, and not having the least cohesion." (Ibid. p. 202.) This appearance is contrasted with that of blood in pleuro-pneumony, in which it " was very thick and viscid, and on growing cold was covered over with a whitish, and as it were Ieather-likt> pellicle :" (p. 203.) Such are still the appearances of the blood in various fevers, simple and complicated. But an entirely new series of observations is required, in order that the subject may be raised to the level of science in the other branches of medicine. The morbid appearances of the blood in typhus fever have been particularly noticed by Dr. Twee- die, in his " Clinical Illustrations of Fever." He states, that in this class of fevers the crassamentum of the blood, instead of forming a firm coagulum, is loose, small in proportion to the quantity of serum, and so soft that it breaks readily on at- tempting to raise it, resembling in consistence half-boiled currant jelly; and that in some in- stances, when abstracted late in the disease, it scarcely coagulated at all. The state of the blood in yellow fever has been lately particularly and ably brought before the pro- : fession by Dr. Stevens. (See Observations on the Blood : read at the College of Physicians, May 3, 1830.) Dr. Stevens observes—"On examining, soon after death, the black and dissolved blood that had been taken from the heart of those who had died of the yellow fever, it was very evident, even at first sight, that several great changes had taken place. " 1st. The blood was more fluid than natural, , partly from an excess of serum, probably produced by a stoppage of the secretions and the retention of those fluids in the system, which ought to have been thrown out by the secreting organs ; but in- I dependently of this, in these violent continued fevers, as little nourishment is used, the fibrine or solid part does not appear to be formed in its usual quantity, and perhaps, also, it is exhausted faster than in health, in supporting the high and con- tinued excessive heat, that is so great in the com- mencement of the inflammatory form of that fever. In the first stage of the disease, the structure of the red globules is frequently deranged, which is evident from the fact, that in those fevers the colouring matter is often detached from the glo- bules and dissolved in the serum, giving to that part of the blood, when it separates from the fibrine, a bright scarlet colour, and this colouring matter cannot be separated from the serum, either by filtration or any other mechanical means; but as the disease advances, this red colour is lost, and the whole circulating current becomes black, and so thin that it has no longer any resemblance to the blood of health. " 2d. The colour of the whole mass of blood, both in the arteries and veins, was changed from its natural scarlet, or modena red, to a dark black. I have frequently filled one glass with the black fluid taken from the heart, and another with the black vomit taken from the stomach. They were both so unlike the blood of health, and resembled each other so completely, that it was almost im- possible to distinguish the one from the other; and from its appearance it was very evident that such diseased blood could no more stimulate the heart or support life in the solids, than putrid water can nourish vegetables, or carbonic acid gas support respiration. " 3d. In violent continued fevers, the saline matter, like the fibrine, appears to be exhausted faster than it enters the circulation ; the blood soon loses a great proportion of its saline impreg- nation ; it loses entirely its saline taste ; and we shall afterwards see that the black colour is a cer- tain proof of the entire loss, or at least of the great diminution of the saline matter. " 4th. The blood, though dissolved, was yet not putrid ; for the blood is so essential to life, that putrefaction of this fluid cannot exist in a living body. But dissolution is the first step towards putrefaction ; and when this to a certain degree takes place, death of all the solids must follow. I may here add, that this dissolved state of the viral fluid was the cause, and not the effect of death; for I have sometimes seen the blood, even pre- viously to death, both black, and so thin that it 294 BLOOD, (MORBID STATES OF) could scarcely be retained within the vessels; and occasionally it has been observed oozing from the tongue, the eyes, the skin, and other surfaces, where there was not even the slightest lesion. " The dissolved state of the blood is the effect and not the cause of fever. But as it was evident in many of the fatal cases, that this dissolution was the sole cause of death, it then became an object of importance to find out some agent capa- ble of preventing this fatal change in the whole circulating current" " In the Asiatic cholera, on the other hand, the blood becomes of an unnaturally dark colour and thick consistence." Considerable changes are induced in the blood in inflammation. It is well known that the blood drawn in inflammation of the serous membranes is apt to be cupped and buffed ; that is, the cruor is firm and contracted, and its edges are much raised above the central part of its surface; and its upper portion consists in a substance nearly deprived of colouring matter. This buff consists of fibrine and albumen ; the serum contains more albumen than natural; and the crassamentum is exceedingly firm. Is this modification of the blood the effect, or a cause, of the inflammatory process ? That the blood may be cupped and buffed independently of inflammation, is proved by the facts of the occur- rence of these phenomena in cases of pregnancy. It is true, on the other hand, that the buffed and cupped state of the blood is not so obvious on the first day as on subsequent days, in cases of inflam- matory disease. It must therefore be concluded that inflammation, and the state of pregnancy, and other sources of excitement, and even blood- letting itself, when so conducted as to lead to re- action, induce the cupped and buffy state of the blood. It is an interesting fact to note, that the layers and adhesions formed upon or from the surfaces of inflamed serous membranes, are of the same chemical and physical constitution as that of the buff of the blood itself. It is important to remark that it is not every kind of inflammation which induces the cupped form and buffy coat in the blood. Inflammation of the serous membranes and parenchymatous substance has chiefly this effect. 'Inflammation of the mucous membranes, as bronchitis, and dysenteria, frequently occurs without any disposi- tion to a cupped or buffed condition of the blood. Indeed, there is a greater difference between these two classes of disease than their names would lead us to suspect. Dr. Tweedie has observed, in two instances of acute disease, the buffy coat on arterial blood. The only reason why this appearance is not so familiar to us is, probably, the less frequent per- formance of arteriotomy than of venesection. But besides the marked morbid appearances of the blood in fever and in inflammation, very pecu- liar changes take place in chlorosis. In this dis- ease there is a general state of bloodlessness; the crassamentum is small, the proportionate quantity of serum large; a drop of the blood observed upon white linen is seen to be extremely pale. It still remains to ascertain the exact proportions of fibrine, albumen, ha:matosine, &c. in chlorotic blood, and to observe its appearance under the microscope. It still remains to compare it with the blood of persons blanched by hemorrhagy. The morbid character of the blood in chlorosis must be ranked amongst the most unequivocal proofs of the truth of a humoral pathology. The next disease to be noticed in connexion with the pathology of the blood is scorbutus, the stronghold of the humoral pathologists,—the pons asinorum of the solidists. The defective cohesion and separation of the cruor, the " dissolved" state of the blood in scorbutus, could never be forgotten by either party; it was continually reproduced by the former, and pertinaciously neglected by the latter. Dr. Mead gives a vivid description of the state of the blood in scorbutus. " In the beginning," he observes, (Medical Works, Dublin, 1767, p. 332,) " as it flowed out of the orifice of the wound, it might be seen to run in different shades of light and dark streaks. When the malady was increased, it ran thin, and seemingly very black; and after standing some time in the porringer, turned thick, of a dark muddy colour, the surface in many places of a greenish hue, without any regular separation of its parts. In the third degree of the disease it came out as black as ink ; and though kept stirring in the vessel many hours, its fibrous parts had only the appearance of wool or hair floating in a muddy substance. " In dissected bodies the blood in the veins was so entirely broken, that by cutting any considera- ble branch you might empty the part to which it belonged of its black and yellow liquor. When found extravasated, it was of the same kind. And lastly, as all other kinds of hemorrhage are fre- quent at the latter end of the calamity, the fluid had the same appearance as to colour and con- sistence, whether it was discharged from the mouth, nose, stomach, intestines, or any other part." There is no point in pathology more instructive than this of scorbutus. The morbid influence of salt meat, and the curative influence of acids ; the baneful effects of impure air and impure diet, and the beneficial effect of a change of atmosphere and regimen ; are shown more clearly in this dis- ease than in any other. And as subsequent links of the chain, the influence of a "dissolved" state of the blood in inducing a " dissolved" state of the solids, to use the ancient phraseology, is equally remarkable in this disease. Nearly allied to scorbutus is purpura. Some singular appearances have been observed in the blood in this disease. The crassamentum has been found separated without being firm, or con- tracted ; and buffed without being cupped; its upper surface covered to a considerable depth by a straw-coloured substance resembling ordinary j jelly. This, as well as the other parts of this in- , teresting subject, still needs further investigation. As an improper kind of diet produces a baneful influence upon the composition of the blood, so does a disordered and haded state of the bowels. This is apparent from the condition of the secre- tions : the saliva, the perspiration, the urine, are , alike deranged in their obvious qualities, but espe- BLOOD, (MORBID STATES OF) 295 cially in odour ; and there is more or less of the bloodless appearance seen in chlorosis. Icterus is another disease in which the blood is known to suffer. The colouring principle, at least, of the bile is retained in the blood. It appears to act as a narcotic upon the brain, inducing drow- siness. The serum of the blood and the secre- tions from the skin and kidney are in some cases alike tinged with the yellow colouring matter of the bile. Every one knows the baneful influence of a suppressed state of another secretion—the urine. It cannot be doubted that some of the principles of this secretion are retained in the blood. Pre- vost and Dumas found urea in the blood of an animal in which the ureters had been tied. In the human subject, suppression of the urine, or the presence of some of its principles in the blood, produces coma and death. M. Dance has recently renewed the idea of a former day, that the suppression of the secretion of milk may, like that of the bile or urine, affect the blood and the secretions. In one such case it is said that caseum was found in the fluid of ascites, evacuated from the abdomen. But if the secretions become sometimes sup- pressed, and produce a reflex alteration in the blood, there is a case in which the blood becomes morbidly affected, together with an excessive se- cretion, as in diabetes. The blood in this disease is more serous, and contains less fibrine than usual. It would be interesting to examine the effect upon the blood of excessive perspiration, undue lacta- tion, and profuse or protracted menorrhagia or leu- corrhoea. The facts which result from this inquiry are these:—1. In many diseases, as fever, inflamma- tion, chlorosis, scorbutus, there are undoubted morbid changes induced in the blood itself; 2. that other morbid changes are induced by impure atmo- sphere and an unwholesome diet; 3. that various miasmata in the atmosphere, and various poisonous qualities in food, produce morbid changes in the blood ; 4. that suppressed secretions induce mor- bid changes in the blood ; 5. that excessive secre- tions induce other morbid changes in this fluid ; and, 6. that an affection of the innervation, or of the nervous system, may, as is observed on a divi- sion of the eighth pair of nerves, produce its pe- culiar changes in the circulating mass. The practical indications resulting from these and other morbid states of the blood will be no- ticed under the head of diseases in which they chiefly are found. We consider their statement in this place as highly important in a practical point of view. Marshall Hall. [Hxmatology, or the examination of the blood, has engaged the attention of many excellent ob- servers of late years, and with much advantage to science. When the blood is circulating in the vessels it consists of a homogeneous fluid, to which Dr. B. Babington (Cyclopxdia of Anat. and Physiol, vol. i. p. 415, Art. Blood, morbid condi- tions of the) has given the name Liquor Sangui- nis, and of Red Corpuscles. The difference between living and coagulated blood may be expressed in a tabular form as follows : Liquor Sanguinie,\Fatty MdtleT' Albumen, (Water, ) j Various Salts, | } Serum. Extractive do., j i Albumen, J [Fibrin, ) Crassamen- \ turn. , Red Corpuscles. The analysis of the blood by M. Lecanu is generally regarded the most complete that has been made (Journal de Pharmacie, vol. ix. & x, Paris, 1831, and H. Milne Edwards, Art. Blood, in Cyclop, of Anat. and Physiol., vol. i. p. 411.) The careful examination of the blood of two strong and healthy men afforded the following results : 1st Analysis. ' 2d Analysis. Water......................... Fibrin ......................... Albumen....................... Colouring Matter............... Fatty crystallizable Matter...... Oily Matter.................... Extractive Matters soluble in al- cohol and in water............ Albumen combined with Soda... Chloride of Potassium.......... Chloride of Sodium............. Alkaline Subcarbonates......... Alkaline Phosphates............ Alkaline Sulphates............. Subcarbonate of Lime.......... Subcarbonate of Magnesia...... Phosphate of Lime............. Phosphate of Magnesia......... Phosphate of Iron.............. Peroxide of Iron................ Loss........................... Total.................... 1000,000 780.145 2.100 65.OH0 13:1.000 2.430 1.310 1.790 1.265 8.370 2.400 788.500 3.565 60.415 119.626 4.300 2.270 1.920 2.010 7.304 1.414 2.586 A long series of connected hematological ob- servations has been made by M. Andral, both alone and in association with M. Gavarret and M. De La Fond (Annales de Chimie et de Physique, torn. Ixxv. & 3me serie, torn. v. and Hematologic Pa- thologique, Paris, 1843), which have developed interesting results. Their inquiries were directed to the variations in the proportion of certain prin- ciples of the blood, as the fibrin, corpuscles, solid matters of the serum and water, both in the healthy and morbid state. The method adopted for this purpose was as follows :—The blood was made to flow into two different vessels. Into one, the first and last quarters of the blood were re- ceived ; and into the other the second and third quarters ; in order that the similarity of the two quantities might be attained as far as practicable. The blood in one vessel was permitted to coagu- late spontaneously ;—that in the other vessel was beaten with a small rod in order to separate the fibrin. When the first portion had completely co- agulated, the serum was carefully separated from the crassamentum; and they then dried and weigh- ed, first, the librin obtained by the rod ; secondly, the whole crassamentum; thirdly, the serum. The weight of the separated fibrin gave the quan- tity of it contained in the clot The weight of the scrum after complete desiccation gave the pro- portional quantity of solid matter contained in its water. The quantity of water driven off from the, clot in drying gave the amount of serum it contained ; from which the proportion of the solid matter of the serum that the crassamentum con- tained could be estimated. Hence, by deducting from the weight of the whole dried clot, first, that of the fibrin separated by agitation, and then that of the solid elements of the serum, ascertained by 296 BLOODLETTING. calculation, the weight of the red corpuscles was obtained. In order to ascertain the whole amount of solid matter in the serum, that which was as- certained by calculation to exist in the fibrin was added to that which was obtained from the sepa- rate serum. The proportion of inorganic and of organic matter in this solid residuum was ascer- tained by incinerating it in a crucible ; by which the whole of the former was driven off, whilst the latter was left. These researches have shown, that the average amount of fibrin in human blood is 3 parts in the 1000. In persons in health, the amount of fibrin may oscillate around this average so as to descend as low as 2.5 ; or ascend as far as 3.5; without actual disease existing. M. Andral, indeed, (He- matologic, &c. p. 28.) affirms, that some indi- viduals, without being sick, have the ratio as high as 4 ; whilst others have it as low as 2 ; but these are rare cases, and belong to peculiarities of con- stitution or to idiosyncrasies. The average quantity of red corpuscles in healthy man was found to be 127 ; the maximum being 140 ; and the minimum 110. The maxi- mum 140 is, however, according to M. Andral, associated with a state of plethora, which, when developed, is really morbid. Strength of consti- tution contributes most to raise the corpuscles to- wards their maximum, whilst congenital, or ac- quired weakness, depresses them towards their minimum. The average proportion of the solid matter of the serum was found to be 80. It, also, is liable to variation within certain limits in the state of health; but whenever it passes those limits, disease exists. The results of the observations of recent haema- tologists, in special diseases, will be given under those diseases. „ _. ., Robley Dunglison.] BLOODLETTING. The detraction of blood is either general or topical: the first consists of phlebotomy or venesection, and of arteriotomy; the second, of leeching, cupping, and scarifica- tion. As general bloodletting is, of all our remedies, the most powerful, its employment requires the utmost consideration and precaution. If we neg- lect this remedy in cases in which its use is re- quired, we allow the disease to make a dangerous progress ; on the other hand, if we employ it in- advertently and inappropriately, we induce a dan- gerous state of debility or exhaustion. It will, therefore, require much care to lay down such rules as may guide, or, at least, assist the young practitioner in the due and efficient, but appro- priate and cautious, use of bloodletting. Of the circumstances which require considera- tion in the prescription or performance of blood- letting, the principal are, 1. the nature and stage of the disease; 2. the velocity and the force of the action of the heart; 3. the condition of the pulse at the wrist; 4. the appearance of the blood ; and, 5. the effect upon the patient, in arresting the symptoms, subduing the disease, or in inducing syncope. In regard to the repetition of the blood- letting, the same circumstances must be considered, in conjunction with the actual state of the symp- toms, the appearances of the blood previously drawn, &c. The diseases which require bloodletting are chiefly inflammation, diseases of the head, and some forms of fever. Of the first class it is re- marked, that inflammations of the serous mem- branes and of the substance of organs require bloodletting much more than inflammations of the mucous membranes : arachnitis, pleuritis, perito- nitis, pneumonia, hepatitis, require general blood- letting far more than bronchitis or dysentery. The second class, or affections of the head, con- sist either of inflammatory, congestive, or organic disease, as arachnitis, apoplexy, tumours; or of what may be termed affections of nervous irrita- bility, such as are observed from intestinal derange- ment, exhaustion, &c. and in delirium tremens, the delirium traumaticum described by M. Du- puytren, &c. Now the diseases of the former of these subdivisions require bloodletting proportioned to their severity; whereas in those of the latter the detraction of blood requires great caution. Laennec assures us that the force of the beat of the heart under the stethoscope is an excellent criterion and guide for the use of the lancet. As this point does not appear to have excited further attention, it will be especially proper to introduce the remarks of that eminent pathologist in this place: " In all cases in which the pulsations of the heart are, proportionately, more energetic than those of the arteries, we may bleed fearlessly and be certain of an improvement in the state of the pulse. But if the heart and the pulse be alike feeble, bloodletting will almost always precipitate the patient into a state of complete prostration." (De I'Auscultation, t. i. p. 486-7.) Laennec adds, (T. ii. p. 481.) "the certainty and facility with which the stethoscope affords or excludes the indi- cations for bloodletting, appears one of the great- est advantages conferred by this instrument." It must be confessed, however, that as the pulse may be "fictitie debilis," or apparently, not really, a mark of weakness, so the beat of the heart may be apparently, rather than really, strong; this oc- curs in cases of mere nervousness, and in one stage of exhaustion. But in the instances from which such sources of error are excluded, it is plain that an attention to the force of the beat of the heart may be of the utmost advantage. The condition of the pulse is also one of those circumstances which greatly assist us in the ad- ministration of bloodletting. But that we may derive all the advantage possible from the state of the pulse, it must always be considered in con- nexion with the disease. Thus in enteritis, al- though an inflammatory disease, the pulse is small and feeble, and would not to the inexperienced suggest the propriety of the essential remedy, bloodletting; in a certain stage of exhaustion from loss of blood, on the other hand, the pulse is bounding and strong, and the ignorant or incau- tious practitioner might be led by it to an impro- per and unsafe detraction of blood. Still the pulse, taken in this connexion, is an important guide to us for the use of the lancet; its strength indicating, its feebleness contra-indicating, the de- traction of blood. [Mere quickness of pulse—taken singly—can never be regarded as a positive indication for the use of the lancet, inasmuch as it occurs in dis- eases which are highly neuropathic, and especially BLOODLETTING. 297 where they are accompanied at the same time by debility ; and the practitioner who expects, under such circumstances, to diminish the velocity of the circulation by bloodletting, will find himself wofully mistaken. In scarlatina, quickness of pulse is one of the most marked functional phe- nomena, and in the most malignant cases this is often most strikingly evinced ; yet bloodletting can rarely be employed in such cases, and if it should be, it will generally be found, that the quickness of pulse is increased rather than dimi- nished by it (See, on the whole subject of Blood- letting, Dunglison's General Therapeutics and Materia Medica, ii. 150: Philad. 1843.)] During the flow of blood itself, great attention must be paid to the state of the pulse ; if it grow larger, fuller, stronger, the propriety of taking more blood is distinctly determined; if, on the contrary, it becomes feebler, the further flow of blood must be arrested. In some cases the blood flows well, and displays only a proper degree of the venous hue ; in other cases it flows tardily or scarcely at all, and is of an unusually deep livid hue. The former state of things affords an indication of the propriety of proceeding with the detraction of blood ; the lat- ter warns us of the necessity for the greatest cau- tion in regard to this measure. This distinction has been recently particularly insisted on in re- gard to fever by Dr. Tweedie, in his work on that subject. It sometimes occurs, however, that the blood flows ill at first, and better shortly afterwards. This is particularly observed in those cases which are attended by a small pulse, and a cold, livid surface, as enteritis. This improvement in the flow of the blood from the vein must be viewed as an indication of the propriety of allowing the blood to flow on. A change in the appearance of the blood, as it flows, from the more livid to the less livid hue, must also be considered as indicating the propriety of the still further detraction of blood. The effect of the flow of blood upon the patient is also to be strictly attended to. If pain for in- stance, or any other symptom of an inflammatory disease, remain unsubdued, it is frequently right to continue the abstraction of blood. If, whilst the strength is good, stupor in apoplexy, or pain in pleuritis, remains unmitigated, the blood must be allowed to flow. When, on the contrary, the disease or the symptom is alleviated or re- moved, we are frequently to arrest the flow of blood, and to wait and watch the subsequent state of the patient and of the symptoms; to re- peat the bloodletting if the symptoms return and the strength of the patient remain good, and vice versS. But of all the criteria for the regulation of gene- ral bloodletting, the effect of the detraction of blood upon the patient, in inducing syncope, is, in our opinion, the most important The princi- ple of this criterion is only applicable in cases in which it has been previously judged right to re- commend the full effect of bloodletting; but in such cases it appears to afford the precise measure to which that bloodletting should be carried. The principle alluded to may be stated thus : —I. cxteris paribus, some diseases enable the Vol. I. — 38 system to bear a greater loss of blood than in health : 2. other diseases, on the contrary, induce an unnatural susceptibility to the effects of loss of blood : 3. these two points are severally esta- blished by placing the patient perfectly upright, and letting blood from a moderate-sized orifice until incipient syncope be induced, the quantities of blood which flow denoting the power or the susceptibility of the patient in regard to the loss of blood : 4. this effect is also accurately indica- tive of the quantity of blood which should be abstracted in order to subdue the disease. It is found, for instance, that in arachnitis and apoplexy much blood flows before there is any symptom of approaching syncope .- it is also well known that it is necessary to abstract much blood in these diseases before the chain of morbid actions can be broken. It is probably not so well known that these two facts are precisely commensurate with each other; so that to bleed to incipient syn- cope is to bleed precisely according to the exigen- cies of the case. Pleuritis and pneumonia not only require, but enable the patient to bear the abstraction of a large quantity of blood : bronchitis, on the other hand, neither bears nor requires much loss of blood. In any case, if we place the patient upright and bleed to incipient syncope, we abstract precisely the quantity of blood which the patient will bear to lose, and which the disease requires to be with- drawn. Similar remarks apply to peritonitis, and what has been termed muco-enteritis. In other cases there is a difficulty in the diag- nosis, and there may be symptoms resembling arachnitis, pleuritis, peritonitis, without inflam- mation : such symptoms are apt to arise merely from a loaded and deranged state of the stomach or of the bowels; some indigestible substance taken under circumstances of susceptibility, as in the puerperal state; the presence of scybala, or unhealthy secretions. The intestines, under simi- lar circumstances, induce pain and affections of the head or abdomen so similar to inflammation, as not easily to be distinguished from it. In such cases we may, however, safely place the patient erect, and bleed to incipient syncope. Whereas in arachnitis we frequently abstract thirty, forty, or fifty ounces of blood, or even a still greater quantity,—in these cases the loss of ten, twelve, or fourteen ounces will frequently induce the most decided syncope. We are thus furnished at once with the due measure of the remedy and the diagnosis of the disease. The same rule applies in the early stage of fever, in which, if there be great constitutional power and excitement, or inflammation, much blood must and will be drawn; whereas, in cases of an opposite kind, there will be early syncope —our safeguard against withdrawing an undue quantity of blood. Having stated and explained the general prin- ciple, it only remains to add that several precau- tions are required in carrying it into practice. We must not be deceived by that kind of fainting which occurs from timidity in regard to the mere operation. We must not be misled by the state of things very early and very late in the disease. BLOODLETTING. In the former case the disease has not induced its influence upon the system ; in the second it has led to sad devastation of its powers, as well as of the structure of the organ affected. Chlorosis and every form of dyspepsia are amongst the diseases which neither bear nor re- quire bloodletting. There are diseases which may be benefited by the detraction of a small quantity of blood, but in which full bloodletting would not be proper. Such are, some cases of haemoptysis, diabetes, and probably the cholera. In regard to these, experience of the past alone can guide us in the future. The principle just adverted to is only applicable in cases in which the full effects of bloodletting are required, not exceeding the limits of efficiency on one hand, and of safety on the other. The next point to be determined is the repeti- tion of the bloodletting. The strength of the patient, the force of the symptoms, the beat of the heart and of the pulse, must again aid us in our decision. But it is important to remark, that if at the first bloodletting much blood should flow before syncope is induced, it must be received as a criterion that the disease may require, as the patient will bear, the early and efficient repetition of the remedy. Much importance has been attached to the appearance of buff upon the blood, as an indica- tion for further bloodletting. This appearance, however, if trusted to alone as a guide, is very apt to mislead the practitioner. It occurs in many other cases besides inflammation, and especially in almost all puerperal diseases. A patient has been daily bled in puerperal mania, on accouut of the constant appearance of buff on the blood, and bled to death ! Dr. Willan makes an excel- lent remark on this subject. " Some practition- ers," he observes, " continue to let blood in most cases of acute rheumatism, thinking themselves justified in their mode of practice by the sizy appearance of the blood. The same principle would lead them to empty the whole sanguiferous system; for every time bloodletting is repeated, the blood becomes more and more dense or sizy." (Diseases of London, 1821, p. 261.) Not only is buff induced by other causes besides inflamma- tion, but in some cases of inflammation it does not exist. Much, too, depends upon the mode in which the blood flows from the vein, and other circumstances. So that the light cast upon the treatment of diseases by this circumstance is feeble, if not actually deceptive. The " dissolved" state of the blood, and the small quantity of crassamentum compared with the serum, form a more certain contra-indication of bloodletting, generally speaking ; and yet even this is probably not absolute. The different modes of general bloodletting are venesection, performed in the arm or foot, or in the neck; and arteriotomy. It is almost needless to mention that the arm is generally preferred. The jugular vein, how- ever, should be opened when the head is affected. But it is principally useful to have recourse to the incision of the jugular vein in children, in whom it is readily opened, and in whom the veins of the arms are small. Arteriotomy is preferred principally in cases of disease of the head or of the eye, or in cases in which blood cannnot be obtained from the veins. Local bloodletting is chiefly applicable as an auxiliary to general bloodletting, and in local dis- eases in which general bloodletting is not required. In cases of inflammation within the head, chest, or abdomen, after the due abstraction of blood generally, the local abstraction of blood is very often employed most opportunely. The second remedy secures the benefit which the first had conferred. In regard to the application of a large number of leeches in such cases, a few words of caution are, however, necessary. The loss of the blood so withdrawn is not always well borne when the lancet has been used efficiently just be- fore ; and if applied late at night, the flow of blood is apt to continue unheeded, until an undue quan- tity of blood has been poured out. Both these events have occurred, and led to unavailing regret Cupping is, generally speaking, a more efficient remedy than leeching. It is most appropriately applied to the nape of the neck, behind the ears, to the temples, to the various parts of the chest, over the region of the liver, the kidney, &c. To the softer parts of the abdomen, leeches must be applied. Both these remedies are peculiarly efficacious in cases in which the powers of the whole system have been duly subdued by general bloodletting, without the removal of the symptoms of the local disease. Only the quantity so withdrawn after the general bloodletting must not be too great. In some chronic local affections, in which gene- ral bloodletting would be inadmissible, the local abstraction of blood by leeches or cupping be- comes our chief remedy. Such cases are chronic inflammation within the head, thorax, or abdo- men ; especially when this is fixed chiefly to one part or organ. Inflammatory pain long confined to one part of the head or chest, chronic inflam- mation of the liver, kidney, uterus, &c. are cases in which local bloodletting is the appropriate re- medy. It should not be omitted, perhaps, that the ap- plication of leeches near the anus has been much recommended in France, in order to effect what is supposed to be effected by hemorrhoidal dis- charges, viz. to unload the vena ports, and to relieve the head or the liver. This mode of local bloodletting is also very beneficial in diarrhoea and dysentery. Leeches have also been applied by means of an appropriate metallic tube to the vagina or to the os uteri, in cases of inflammation of those parts. These appear to be appropriate cases for the use of local bloodletting by cupping and leeches. Scarification is a mode of taking blood in a few cases of local disease, as in inflammation of the eye, of the tonsils, and in inflamed hemorrhoids. Morbid Effects of loss of Blood.__The morbid effects of loss of blood may be divided into the immediate and the more remote.- the for- mer occur at the moment of the excessive detrac- tion of blood or of profuse hemorrhagy; the latter, at a more remote period, or during the course of a continued drain from the sanguiferous system. The immediate morbid effects of loss of blood are, syncope, convulsion, delirium, coma, sudden BLOODL dissolution; the more remote are, excessive re- action, mania, coma, amaurosis, sinking. In ordinary syncope from loss of blood, the patient first experiences a degree of vertigo, to which loss of consciousness succeeds ; the respi- ration is affected in proportion to the degree of insensibility, being suspended until the painful sensation produced rouses the patient to draw deep and repeated sighs, and then suspended as before; the beat of the heart and of the pulse is slow and w eak; the face and general surface be- come pale, cool, and bedewed with perspiration ; the stomach is apt to be affected with eructation or sickness. On recovery there is perhaps a momentary delirium, yawning, and a return of consciousness ; irregular sighing breathing, and a gradual return of the pulse. In cases of profuse hemorrhage the state of the patient varies : there is at one moment a greater or less degree of syncope, then a degree of reco- very. During the syncope the countenance is extremely pallid ; there is more or less insensi- bility ; the respiratory movements of the thorax are at one period imperceptible, and then there are irregular sighs ; the pulse is slow, feeble, or not to be distinguished ; the extremities are apt to be cold ; the stomach is frequently affected with sickness. There are several phenomena observed in this state particularly worthy of attention. We have remarked that, when the movements of the chest have been imperceptible or nearly so, in the interval between the 6ighs, the respiration has still been carried on by means of the diaphragm. It may also be observed that the state of syncope is often relieved, for a time, by an attack of sick- ness and vomiting, immediately after which the patient expresses herself as feeling better; and the countenance is somewhat improved, the breathing more natural, and the pulse stronger and more frequent. It may be a question, in this case, whether the state of syncope increases until it induces sickness ; or whether the stomach be nauseated by the ingesta usually administered, and the syncope be, in part, an effect of this state of the stomach. In any case, the efforts to vomit are succeeded for a time by an ameliorated state of the patient. In cases of fatal hemorrhagy there are none of these ameliorations. The symptoms gradually and progressively assume a more and more fright- ful aspect: the countenance does not improve, but becomes more and more pale and sunk ; the consciousness sometimes remains, until at last there is some delirium ; but every thing denotes an impaired state of the energies of the brain ; the breathing becomes stertorous, and at length affected by terrible gasping; there may be no efforts to vomit; the pulse is extremely feeble or imperceptible ; the animal heat fails, and the ex- tremities become colder and colder in spite of every kind of external warmth ; the voice may be strong, and there are constant restlessness and jactitation; at length the strength fails, and the patient sinks, gasps, and expires. Convulsion, as an immediate effect of loss of blood, occurs when bloodletting has been inappro- priately or unduly employed, or from excessive hemorrhage. It is apt to occur in cases in which the patient has been bled in a more or less recum- ETTING. 299 bent position, in which the blood has flowed slowly, or in which time has been lost during the operation. In such cases much blood flows be- fore syncope is induced — too much to be safe. When the blood flows slowly, we should be cau- tious how we bleed to deliquium even in the erect posture ; in the recumbent posture it will always be attended with danger. The more usual occurrence of convulsions is from hemorrhagy. In this manner such convul- sions occur after parturition, and constitute one form of puerperal convulsions. A more frightful and formidable disease it is impossible to witness. The countenance and the limbs are variously con- torted, the respiration is laborious and stertorous, and foam issues from the mouth; the colour of the face is deepened, and may be designated as being of a palish lividity. Such a case calls for the utmost presence of mind. The alarm of the by-standers must be quieted. No hasty measures must be adopted. The recumbent posture, the sprinkling of cold water upon the face, a cold lotion applied to the head, and frictions to the feet, are the immediate remedies; stimuli and opiates, with nourishment, are to be administered during the intervals of convulsion. Sometimes, instead of convulsions, a fit of de- lirium occurs; in other, rarer, cases, we may have both delirium and convulsions. This delirium is generally of short duration; it has, in other in- stances, continued so long as to deserve to be con- sidered as mania. A state of coma is another form of the morbid effects of loss of blood. Con- vulsion frequently terminates in coma, but the latter symptom may arise without the former. Of these effects of loss of blood, delirium chiefly occurs in adult age; convulsions frequently occur both in adults and in infants; the state of coma is most frequent in infancy. The last case con- stitutes one of those affections which are apt to i be mistaken for hydrencephalus. Amongst the immediate effects of loss of blood i must be mentioned that of sudden and unexpected dissolution. The patient does not recover from a state of syncope; or, without syncope, he may gradually sink after blood-letting. This event is particularly apt to occur if the patient be bled in the recumbent position. It has taken the most able and experienced practitioners by surprise. At various periods after the profuse loss of blood, whether by bloodletting or hemorrhagy, that state which has been termed re-action occurs. This state of excessive re-action is formed gradu- ally, and consists, at first, in forcible beating of the pulse, of the carotids, and of the heart, ac- companied by a sense of throbbing in the head, of palpitation of the heart, and eventually perhaps of beating or throbbing in the scrobiculus cordis, and in the course of the aorta. This state of re-action is augmented occasionally by a turbulent dream, mental agitation, or bodily exertion. At other times it is modified by a temporary faint- ness or syncope. There is also sometimes irregu- I larity of the beat of the heart and of the pulse. In the more exquisite cases of excessive re-ac- tion, the symptoms are still more strongly marked, and demand a fuller description. The beating of the temples is at length accom- panied by a throbbing pain of the head, and the 300 BLOODLETTING. energies and sensibilities of the brain are morbidly augmented; sometimes there is intolerance of light, but still more frequently intolerance of noise, and of disturbance of any kind, requiring stillness to be strictly enjoined, the knockers to be tied, and straw to be strewed along the pave- ment ; the sleep is agitated and disturbed by fearful dreams, and the patient is liable to awake, or to be awoke, in a state of great hurry of mind, sometimes almost approaching to delirium ; some- times there is slight delirium, and occasionally even continued delirium; more frequently there are great noises in the head, as of singing, of crackers, of a storm, or of a cataract; in some instances there are flashes of light; sometimes there is a sense of great pressure or tightness in one part or round the head, as if the skull were pressed by an iron nail, or bound by an iron hoop. The action of the heart and arteries is morbidly increased, and there are great palpitation and visible throbbings of the carotids, and sometimes even of the abdominal aorta, augmented to a still greater degree by every cause of hurry of mind or exertion of the body, by sudden noises or hur- ried dreams or wakings; the patient is often greatly alarmed and impressed with the feeling of approaching dissolution ; the state of palpita- tion and throbbing is apt to be changed, at differ- ent times, to a feeling of syncope. The effect of sleep is in some instances very extraordinary, sometimes palpitation, at, other times a degree of syncope, or an overwhelming feeling of dissolu- tion. The pulse varies from 100 to 120 or 130, and is attended with a forcible jerk or bounding of the artery. The respiration is apt to be frequent and hur- ried, and attended with alternate panting and sighing; the movement of expiration is some- times obviously and singularly blended with a movement communicated by the beat of the heart; the patient requires the smelling-bottle, the fan, and the fresh air. The skin is sometimes hot; and there are fre- quently general hurry and restlessness. In this state of exhaustion, sudden dissolution has sometimes been the immediate consequence of muscular effort on the part of the patient, or of his being too suddenly raised from the recum- bent into the erect position. The state of re-action may gradually subside and leave the patient feeble, but with returning health; or it may yield to the state of sinking. This term is adopted not to express a state of negative weakness merely, which may continue long and issue in eventual recovery, but to de- note a state of positive and progressive failure of the vital powers, attended by its peculiar effects, and by a set of phenomena very different from those of exhaustion with re-action. In the latter the energies of the system were augmented; in the former the functions of the brain, the lungs, and the heart are singularly impaired. The sen- sibilities of the brain subside, and the patient is no longer affected by noises as before ; there is, on the contrary, a tendency to dozing, and gradu- ally some of those effects on the muscular system supervene which denote a diminished sensibility of the brain, as snoring, stertor, blowing up of the cheeks in breathing, &c. Instead of the hurry and alarm on awaking observed in the case of excessive re-action, the patient in the state of sink- ing requires a moment to recollect himself and recover his consciousness, is perhaps affected with slight delirium, and is apt to forget the circum- stances of his situation, and, inattentive to the objects around him, to fall again into a state of dozing. Not less remarkable is the effect of the state of exhaustion with sinking on the function of the lungs; indeed, the very first indication of this state is to be found in the supervention of a cre- pitus in the respiration, only to be heard at first on the most attentive listening; this crepitus gra- dually becomes more audible, and passes into slight rattling, heard in the situation of the bron- chi and trachea; there is also a degree of labour or oppression, sighing, hurry, blowing, in the breathing, inducing acuteness in the nostrils, which are dilated below, and drawn in above the lobes at each inspiration ; in some cases there is, besides, a peculiar catching laryngeal cough, which is especially apt to come on during sleep, and awakes, or imperfectly awakes, the patient. The heart has, at the same time, lost its violent beat and palpitation, and the pulse and arteries have lost their bounding or throbbing. The stomach and bowels become disordered and flatu- lent, and tympanitic, and the command over the sphincters is impaired. The last stage of sinking is denoted by a pale and sunk countenance, inquietude, jactitation, de- lirium, and coldness of the extremities. It has already been observed that delirium oc- curs as an- immediate effect of loss of blood: mania, or delirium in a more or less continued form, is not an unfrequent occurrence, as a more remote effect of the same cause. That form of this disease termed puerperal mania, generally arises from the loss of blood in the predisposed. A form of mania, not to be distinguished, except by the history of the case, from puerperal manit, occurs from loss of blood, independently of the circumstance of parturition. Coma, amaurosis, deafness, and paralysis are other forms of the effects of loss of blood. Cases of the first kind are detailed by Dr. Abercrombie as well as by the writer of this article. Mr. Tra- vers describes a form of amaurosis from depletion. Deafness from exhaustion is by no means nnfre- quent; and it occasionally remains for a conside- rable length of time. Paralvsis, more or less permanent, occurs occasionally in extreme cases of exhaustion. Various circumstances exert an influence in I diminishing or augmenting the disposition to pre- sent the phenomena of loss of blood. Inflainraa- | tion of the serous membranes and of the paren- chymatous substance of organs protects the system from the effects of loss of blood ; gastric and in- testinal derangements have a precisely contrary effect. It is probable that the mode' in which these circumstances operate is that of inducing different states of the blood itself: inflammation is known to increase the quantity of albumen in blood, and iff general to induce the disposition to I buff; chylopoietic derangements, on the contrary, | induce an opposite condition of the blood. In BLOODLETTING. 301 the • former case the arterial system is probably I more firmly contracted upon its contents, even when a part of these is subtracted; and in this manner the disposition to syncope and to the . other effects of loss of blood may be obviated. Besides the affections described, there are some ' organic effects from loss of blood. There is a disposition to effusion within the head, so that actual apoplexy as well as serous effusion has oc- curred in the last stage of exhaustion. Another effect of exhaustion is effusion into the air-cells and bronchi, giving origin to a peculiar rattle heard with the stethoscope, and generally of fatal omen. Tympanitis is another effect of loss of blood ; and a general disposition to dropsy, inter- nal and external, is amongst the most frequent of the effects of this condition of the system^ The treatment of the effects of loss of blood must be resolved into that which is general or constitutional, and that which is local; and it must vary according to the peculiar state or stage of these effects. Syncope, re-action, and sinking require their appropriate treatment. The consti- tutional treatment must be stimulant in syncope, sedative and soothing in the state of re-action, and restorative in that of sinking. The local treatment must vary with the organ chiefly affect- ed, and with the mode in which it is affected. When syncope assumes a dangerous form, the principal remedies are, an attention to the posture of the patient, stimulants, and chiefly brandy, and the transfusion of blood. The effect of posture is not, even now, fully known. It would be easy to allow the patient to lie over the edge of the bed, the head low upon the floor, and the feet gently raised. In this manner such pressure would be restored to the encephalon as would in many cases support life, until, other remedies being administered, the pa- tient might be placed out of immediate danger. We need not in this place notice the importance of a regulated mode of giving brandy and nourish- ment We think it is frequently given in such quantities as actually to induce sickness and its own rejection from the stomach, and so as to frus- trate the object of the physician completely. The effect should be carefully watched. The physi- cian ought not, of course, in such a case, to leave the patient for a moment The next remedy is transfusion. Unfortunately it has too frequently happened that the proper period of adopting this measure has been allowed to pass by. Not only the vascular system is exhausted, but, after a time, the functions of the nervous system have begun to fail. It might be a question, therefore, whether galvanism might not be usefully conjoined with transfusion. It is an important point to determine how large a quantity of blood the system will bear to receive under various circumstances of exhaustion. Too much may overwhelm; too little may be inade- quate to the accomplishment of the object in view. It is also an important question whether the ope- ration should be done at once, or at twice, or thrice, and with what intervals. As the system cannot bear a sudden reduction of the quantity of blood, so it may not be enabled to bear its too sudden restoration. It is almost needless to add that a due attention must be constantly paid to assist the 2a arterialization of the blood by the admission of fresh air; and to sustain the animal heat by proper clothing, and especially warm applications to the feet If there should be convulsions, delirium, or coma, it may be necessary to apply a sinapism to the nape of the neck ; and in the two former cases some mild sedative, as the tinctura hyoscyami, may be of advantage. In the case of excessive re-action, the remedies j appear to be, first, extreme quiet of body and of ■ the mind ; then, the mildest sedatives, especially the hyoscyamus; thirdly, the mildest nutriments ; and lastly, and above all, time. The pain and throbbings in the head, the in- I tolerance of noises, the general susceptibility to ! disturbance, the palpitations of the heart, alike demand the utmost quiet t0 which every thing soothing in the manner and treatment must be added. The tinctura hyoscyami is, we think, the kindliest anodyne and sedative in these cases. The cause and other circumstances of the case point out the necessity for mild nutriment, to which perhaps the minutest quantities of brandy may be added. It may be necessary to subdue the throbbing action of the head even by local bloodletting; and it is most remarkable how small a quantity of blood being taken will relieve. Two or three leeches are frequently quite sufficient. But the most unequivocal remedy is a cold spirituous lotion, applied all over the head by means of a cap consisting of one fold of stocking. In exhaustion with delirium, the tinctura hyos- cyami should be conjoined, in full doses, with the other remedies. The morbid susceptibility, not only of the brain but of the heart, is greatly assuaged by this remedy. In cases of exhaustion with sinking, stimulants must be administered abundantly. Cataplasms of mustard may be applied to the nape of the neck and to the feet. It is difficult to imagine what would be the effect of a transfusion of blood ; we have no doubt that galvanism would prolong life ; and we should think the two remedies might be conjoined with advantage. In all cases of exhaustion the functions of the bowels suffer. Constipation and flatulency are the usual consequences. These are best relieved by the warm water enema, which must, however, of course, be administered with due precaution, so as to prevent further exhaustion. It is interesting to observe the blunted sensibili- ties in syncope and in sinking, and to compare them with the morbidly acute sensibilities of the state of re-action. Sinapisms to rouse, and the tinctura hyoscyami to lull them, are, in their respective places, remedies of the greatest value. Marshall Hall. BLUE DISEASE. (See Ctanosis.) BRAIN, Inflammation of the.—Under this term we propose to include the pathology, symp- toms, and treatment of the inflammatory affections of the brain and of its membranes. We adopt this plan, not merely because of the intimate rela- tion subsisting between these structures, but be- cause, when we trace the history of a number of acute affections of the encephalon, and examine 302 BRAIN, (INFLAMMATION OF THE)—[MENINGITIS.] the lesions of structure presented after death, we shall frequently find that the substance of the organ as well as the investing membranes has been involved m the disease. Hence arises the difficulty of establishing the diagnosis between inflammation of the parenchyma of the brain and that of its membranes. Both forms of disease have been classed by the majority of nosologiste, ancient as well as modern, under the same head as phrenitis, in consequence of their inability to draw any distinct line of demarcation between their symptoms. Several modern pathologists, however, (Lalle- mand, Rostan, Bouillaud, Gendrin, &c.) having devoted much time and attention to the study of cerebral diseases, and collected a large body of well-observed clinical cases, conceive that they have succeeded in establishing correct rules of diagnosis between several of the inflammatory affections of the brain and of its membranes; and they affirm, moreover, that it is quite possible, in many cases, to ascertain the different degrees, stages, and even seats of cerebral inflammation. The rapid advances made of late years- in the knowledge of the physiology and morbid anatomy of the brain, have no doubt greatly assisted modern observers in discriminating the characters of its various diseases. It is not, in the mean time, improbable that they may, in some instances, have been led, by their zeal in a new field of discovery, to overstep the exact boundaries of fact. We think there is, however, an equal probability that many of our failures in diagnosis, in a class of diseases hitherto so little studied in this country, are to be imputed to a deficiency in our own powers of observation ; the old adage that it is possible to look at an object without seeing it, which is not the less true for being trite, being, we apprehend, often verified in the study of the symptoms of disease. The result of our own experience leads us to the conclusion that there are extreme cases in cerebral affections which can never be mistaken one for another ; that there are cases not so well marked, in which the attainment of an accurate diagnosis is attended with greater difficulty ; that there are also mixed cases, in which one form of disease, which may have existed separately for a time, gives rise to another, or in which a disease, at first local, becomes general. All these circum- stances must necessarily tend to complicate the diagnosis. We should reflect, however, that the study of the pathology of the brain is only in its commencement; that the surest method of ac- quiring greater power of discrimination is to avail ourselves cautiously of the information and expe- rience of those who have already been labouring in the field, and to bring to the further investiga- tion of this intricate subject a spirit of careful observation and strict induction. We may thus reasonably hope to be enabled in time to rectify their errors, extend the sphere of our knowledge, and establish this important branch of pathology on a more, practical foundation. The utmost that can be expected from precise rules of diagnosis, in any class of diseases, is that they should guide us accurately in the great majority of cases ; and altnough it may occasionally happen that they do not accomplish this, they are not on that account to be laid aside as of no value. There is indeed no class of diseases in which the symptoms may not at times prove deceitful; we thus have latent affections of the lungs and alimentary canal with- out any or with only very slight symptoms ; and very decided symptoms of inflammatory or other diseases of these organs without any or at least with only very insignificant disease. When either the arachnoid or pia mater, which closely invest the brain, are extensively inflamed, the functions of this organ become inevitably dis- turbed by sympathetic irritation, without its paren- chyma necessarily partaking of the inflammation; or if the inflammation extends to the parenchyma, it is mostly confined to the superficial layer of cortical substance. This is exactly the manner in which the functions of the lungs or intestines are disturbed in pleurisy or peritonitis. Hence in arachnitis or meningitis, besides headach and intense fever, we have an increase of the general sensibility, preternatural acuteness of the external senses, violent delirium and convulsions, and, finally, collapse, coma, and death. Extensive ! and acute inflammation of the hemisphere of the | brain will be characterized by a nearly similar train of symptoms. In the great majority of cases j the two diseases give rise to each other, and are i thus combined ; it is then extremely difficult, if not impossible, to discriminate between them. There are, however, other forms of cerebral inflam- mation more circumscribed in their seat, and chronic in their progress, respecting the diagnosis of which it cannot, we think, be any longer asserted that the practitioner is altogether left in doubt. We shall now proceed to consider inflammation of the encephalon under two divisions, viz. 1. in- flammation of the membranes of the brain (menin- gitis) : 2. inflammation of the substance of the brain (cerebritis). I. Inflammation of the membranes of THE BRAIN (MENINGITIS). When we look into systematic works on medi- cine, we are at once struck with the confusion which exists in the nomenclature of cerebral dis- eases. Thus the term phrenitis, which has been so long and so generally known that it has passed into popular use, was employed by some of the earlier physicians to designate that delirium which so frequently arises in the course or towards the termination of different diseases; whilst amongst the moderns it is applied to inflammation of the brain or of its membranes. The group of symp- j toms which Frank names encephalitis, is called I phrenis by Vogel, meningitis by Herpin, cepha- | litis by Linnaeus, arachnitis, or more properly, ; arachnoiditis by Martinet: and in different essays and detached publications by various authors, cases strictly analogous are collected together under the denomination hydrocephalus, hydro- cephalic fever, or hydrencephalus. All this has arisen from a difference of opinion as to the seat of the disease, one person considering it as located in the cerebral substance; a second in the invest- ing membranes, viz. the arachnoid membrane, the pia mater, or in both ; whilst a third is altogether taken up with the consideration of the effused fluid and of the means of removing it; notknow- ; ing perhaps that it is a mere consequence or result BRAIN, (INFLAMMATION OF THE)—[MENINGITIS.] 303 of inflammatory action, and not at all an element or a constituent of the original disease. Cullen was decidedly of opinion that we could not, by any reference to the symptoms during life, or the appearances presented after death, assign exactly the seat of the different acute affections within the head; and therefore he included, under the term phrenitis, the inflammations of the different struc- tures contained in the cranium, no matter whether seated in the substance of the organ or in its investments. Mason Good gives what may be considered a qualified assent to this view of the subject He observes that " the disease may commence in the membranes or in the substance of the brain ; and if it were to confine itself strictly to the part first affected, instead of spread- ing from one to the other, there would perhaps be no great difficulty in determining from the symp- toms before us its actual seat; for whilst mem- branous inflammation is accompanied by acute and rousing pain, great heat, and a pulse perma- nently and considerably quickened, parenchyma- tous inflammation is distinguished by a heavy and often stupifying pain, slight increase of heat, pulse irregularly quickened, or sometimes, on the contrary, below the natural standard." As each of these conditions is occasionally presented to us in different cases of cephalitis, we may, says the same writer, infer that in the one instance the disease is seated in the membranes, (inflammatio meningica—phrensy—brain fever,) whilst in the other it is situated in the cerebral substance itself, (inflammatio profunda — acute dropsy of the head.) [Notwithstanding the assertion of some, that meningitis of the different parts of the encephalon may be diagnosticated by certain functional phe- nomena, it is but too true, that it is almost im- possible to pronounce positively, during life, on this matter ; and such is the view embraced by the best pathologists. Happily, it is not a matter of moment, therapeutically ; meningitis, no matter where situate, demanding precisely the same treat- ment] Nothing has contributed more to the diffusion of error in medicine than the disposition so con- stantly manifested to consider symptoms as if they were diseases, and diseases—entities, endowed with individuality or a uniform mode of existence. It also but too frequently happens that effects are taken for causes, and, under the influence of a hasty disposition to generalize, conclusions are drawn from partial observations, confined perhaps to a few detached instances. The opinions enter- tained, and the doctrines taught with regard to inflammation, generally, as a morbid condition, furnish a full illustration of these errors. Are there not many who think and act as if the effu- sion in hydrocephalus were the essence of the disease, and not a result or effect of inflammatory action ? It is with many a fundamental axiom that inflammation softens all textures; hence "ramollissemcnt" or softening comes to constitute the anatomical character of the substance of the brain when inflamed. In point of fact, softening is only a single step or stage in the progress of change, the first departure from the healthy con- dition being a turgid and tense state of the part affected, which subsequently becomes softened; but instead of passing on to suppuration, in some instances the process of disorganization is arrest- ed, and then the part becomes indurated. Pinel was so fully impressed with these views that in- stead of following the usual routine of commenc- ing with a definition of inflammation, he con- sidered under so many distinct heads the inflam- mations of the different primary textures of which the body is composed, indicating the anatomical characters and the peculiar symptoms of each. The arachnoid membrane, for instance, belonging as it does to the class of serous tissues, resembles them in its lesions when diseased, as it does in its character and properties in the healthy condi- tion. Like all the individuals of its class it be- comes, when the subject of different degrees and modes of irritation, the seat of serous and purulent effusions, as well as of exudations of coagulable lymph : and as acute inflammation of the peri- cardium, the pleura, or the peritoneum, are con- sidered as distinguishable by a special train of symptoms, it would be natural to infer that the like lesion of the arachnoid must be attended by its appropriate characteristics. These general views, which are confessedly applicable to inflammation in other parts of the system, would have induced the learned author of the « Nosographie Philosophique," when treat- ing of the cerebral inflammations, to divide them into separate groups, according as they are seated in the membranes or in the substance of the organ. But he was too discriminating an observer to be biassed by a, priori views, or led away by the spirit of the system: he admits, that in order to keep up the unity of his plan, it would be necessary to describe separately cerebritis and meningitis, and to cite cases in which the exist- ence of each could be distinguished by a special train of symptoms. This he found to be im- practicable, and consequently felt himself obliged to include under one head, encephalitis, the gene- ral history and the complex and varying symp- toms of inflammation, whether seated in the membranes or in the substance of the brain. The majority of our practical men subscribe to the correctness of these views ; for they learn by experience that it is much easier to indicate a diagnosis in a nosological table than to support it at the bed-side of a patient. An examination of the structure of the brain, and of the peculiarities of the circulation in it and upon it, would also lead to the inference, that if the meninges be the seat of inflammation, the contiguovis cerebral substance must participate in some degree in the irritative influence. In other organs the vessels, after entering them by trunks and branches of various sizes, branch out and ramify in their interior until they become capillary in their spongy and areolar tissue. But in the brain a different arrangement takes place : the vessels, after entering at the base of the skull, communicate freely with one another, and then branch out upon the surface of the braiu, rami- fying in an extended web of cellular tissue [pia mater] ; in this way they become reduced to so great a degree of tenuity before they enter the substance of the organ, that it may be said to be surrounded by a vascular atmosphere from which its supplies are derived. Hence it is, that as the 304 BRAIN, (INFLAMMATION OF THE)-[MENINGITIS.] meninges and the contiguous cerebral substance are supplied from the same source, each will more or less become affected by any inflammatory ac- tion set up in the other. [Meningo-cephalitis.~\ M. Bayle, in his thesis, gives six cases of what he considers chronic arachnitis, as in all of them the arachnoid membrane was thickened, opaque, and resisting, and there was found some serous effu- sion ; but in five of these cases portions of the cerebral substance were adherent to the mem- branes, and so much softened as to be brought away with the latter when an effort was made to detach them : in five of them also the pia mater was injected, thickened, and infiltrated with serous fluid. MM. Martinet and Parent, in their elaborate monograph on arachnitis, give the results of their examination of one hundred and sixteen cases, published with the expressed design of establish- ing the diagnosis and pathology of arachnitis. But though these cases are classed as inflamma- tions of a serous membrane, we find that in a considerable number of them the inflammation had extended to the cerebral substance, the vessels of the pia mater being at the same time injected, and its substance thickened and covered with a serous or sero-purulent effusion ; so that, judging from the post-mortem appearances, they were in fact mixed cases ; and in strictness we must refer the symptoms or physiological indications pre- sented during life, to the lesions of the cerebral substance rather than to that of the meninges. The brain confessedly presides over all the phenomena which are. attended with conscious- ness, and over every act which is influenced by the will; it is the organ of intellect, and the centre of sensation and of voluntary motion. Moreover, through the pneumogastric nerve, it influences directly the functions of digestion and respiration, and indirectly (through the respiratory apparatus) (hat of the circulation. Experiment also demon- strates its intimate connexion with the regulation of animal temperature. Now if we note the symptoms attributed to inflammation of the arachnoid membrane, or look over the catalogue of them as enumerated by different writers, we shall find that they are but so many lesions or disturbances of one or more of the cerebral func- tions, and as such they must arise from an affec- tion of the organ itself which holds these functions in dependence, and not of the investing mem- branes, which cannot exert on these functions any direct control. Thus, when in a summary of the symptoms of arachnitis we find delirium, >pasm, and rigidity of the muscles, convulsions, vomiting, stupor, coma, contraction or dilatation of the pupils, with strabismus, we must refer them to an alteration in the function or structure of some part of the cerebrospinal mass, and not of its investments merely. The arachnoid and pia :nater are so simple in their structure and func- tion that we can scarcely assign to inflammatory iction when set up in them any other indication except pain or headach. Dr. Abercrombie expressly gives it as his opi- nion, " that our knowledge is not sufficiently, matured to enable us to say with confidence what symptoms indicate inflammation of the substance of the brain, as distinguished from that of its membranes." The difficulty of establishing this I point of diagnosis has been felt by all those who have treated of the subject There are circum- stances, however, in which we can indicate with sufficient precision the symptoms of cerebritis, as | distinguished from any that can in strictness be referred to meningitis ; for instance, when the in- flammation is isolated, and does not reach the membranes, as where it is seated in the thalamus or corpus striatum. If in such a case the attack j does not proceed with unusual violence or rapidity, the pathognomonic symptoms can be traced readily I enough, and no attentive observer would mistake j the disease for arachnitis. But if the inflamma- tion occurs at the circumference of the organ, where the membranes and the cerebral substance i are in contact, and both are supplied by the same | vessels, then, though the inflammatory action j may at the outset be seated in the meninges, it will speedily extend more'or less to the cerebral substance, and, by complicating the lesion, will confuse the diagnosis. We have examined many cases which, on a superficial inspection or hasty examination, would be set down as cases of acute meningitis ; but by carefully elevating the mem- | branes, we could distinctly observe vessels, en- larged and distended, passing into the cerebral [ substance ; and on examining the latter texture j attentively, we could also recognise an increase | of its vascularity, and occasionally some degree [ of change in its colour and consistence. In the i great majority of superficial inflammations there is a mixed lesion, and all that discrepancy which i their progress and symptoms present is explicable I not merely by the extent and degree of the in- flammation, or by peculiar idiosyncrasy, but by the fact that in some of them the inflammatory action is for the most part expended on the mem- branes, the brain receiving but slightly the irrita- tive influence; that in others the reverse obtains; whilst in a third group it seems as if concentrated upon the vessels of the pia mater, the arachnoid on the one hand and the brain on the other being but slightly affected. By viewing the subject in this way, (and we are induced to do so from an attentive consideration of it, as well as from numerous post-mortem examinations,) we shall clearly perceive that the diagnosis of the mem- branous and parenchymatous inflammation in the encephalon has been considered obscure because in very many cases they occur simultaneously. From this mode of considering the subject, it will be obvious that in a practical point of view it is of much more importance to be able to determine what may be considered a previous question, namely, what are the symptoms which indicate inflammation within the encephalon, than nicely to mark its exact location. Cerebral irritations are divisible into two great classes, symptomatic and idiopathic; the former being by far the more numerous. Broussais goes so far as to say that " the brain is of all organs the one which is the least liable to inflammation, inasmuch as it is seldom if ever affected directly, being almost always acted on through its sympa- thetic connexions with other viscera." Sympto- matic irritation is for the most part connected with and dependent on a morbid condition of the chylopoieric viscera. We frequently observe that for weeks previously to the occurrence of pain or BRAIN, (INFLAMMATION OF THE) —[MENINGITIS.] 305 any disturbance in the head, the digestive func- tions have been impaired, the bowels confined or irregular, and the stools unnatural. In many of these cases, when the headach, retching, irregular fever, and even coma, have set in, speedy and permanent relief has followed the use of purga- tives, and the other means usually resorted to for correcting disordered functions. An irritative in- fluence is in such cases propagated from the digestive organs to the brain by reason of the close sympathetic connexion which subsists be- tween them in health and in disease; and that irritation, if kept up for a while, will pass into positive inflammation, marked by its usual con- sequences. The irritation of worms and of teeth- ing may also induce similar results, more parti- cularly in those constitutionally predisposed. We frequently observe these cerebral affections to spring up during the course of other diseases, of which they may be considered as complications ; namely, continued fever, scarlatina, measles, hooping-cough ; and they not unfrequently fol- low accidents or injuries. Hence, says Dr. Abercrombie, it becomes necessary to keep in view those symptoms which set in in the course of these diseases, or follow such accidents, and indicate the existence of a dangerous affection of the head. Referring these to their respective seats, they are as follows :—In the head—head- ach, with throbbing and giddiness, tinnitus, sense of weight and fulness, stupor, and propensity to sleep. In many obscure and insidious cases a constant feeling of giddiness is the only remark- able symptom. In the eye—impatience of light, unusual contraction or dilatation of the pupil, double vision, blindness, distortion of the eyes outwards, paralysis of the lids, causing the shut eye, or the gaping eye. In the ear — unusual acuteness of hearing, great noise in the ears, transient deafness. In the speech — indistinct or difficult articulation, unusual quickness or un- usual slowness of speech. In the pulse—slow- ness, remarkable variations in its frequency. In the mind—transient fits of incoherence, confusion of thought, forgetfulness, high delirium. In the muscles—convulsion or partial paralysis. Whilst examining complex cases of this sort, attention should be directed, not merely to ascertain the existence of a particular symptom, but rather to determine whether there is a correspondence and harmony between the symptoms ; — thus " the peculiar oppression which accompanies a high degree of fever is not considered dangerous, or perhaps unfavourable; but the same degree of oppression without fever, or with a very slight fever, would indicate a head-affection of a danger- ous character." This remark is applicable also to headach and delirium. Acute meningitis. — Under this term we shall include all those cases in which the inflam- matory action has its principal seat in the mem- branes, but in which it is a legitimate matter of inference that an irritative influence is propagated to the contiguous cerebral substance. This affection presents a train of symptoms which varies in different ages and in different temperaments. Its most marked and ordinary character at its outset is an increased sensibility to all sorts of impressions, the ordinary external in- Voi. I. — 39 2a* fluences producing inordinate effects. Thus a child is restless and sleepless, seldom even dozing, or if he does doze, from time to time starting and waking up ; he attends to every sound, the eyes are suffused, the retina is so sensitive to light that he winks or turns away if his face is directed to a window or to a candle ; the pupil is generally contracted, but not invariably so. The head is often moved about, or from side to side, so are the limbs ; the temper is peevish, and nothing seems to soothe this irritable condition but motion up and down the room in the arms of the nurse or attendant. The state of the bowels varies much in different instances ; they may be confined or relaxed, but the stools do not present any unnatu- ral appearance. There is a minor degree of this state which is marked by increased animation and liveliness, which with ordinary observers may pass for an increase of health and vigour, though an attentive observer will readily perceive that the countenance wants that disengaged air which exists in health ; and on making a closer exami- nation he will find that the eyes frequently close and wink, and the countenance assumes an ex- pression as of frowning : the hand, too, is fre- quently raised towards the head, and the fingers are fixedly closed. We occasionally observe in children a state the very opposite of this—a state characterised by a want of animation, accompa- nied by plaintive moaning at times, and an indif- ference to surrounding objects. Though the child does not sleep, yet his state is not that of waking; and if roused, he betrays fretfulness and peevish- ness. These may be considered as so many indi- cations of an incipient irritation, which in some constitutions may arise independently of any as- signable agency, but which in many cases is referable to an irritation propagated to the brain from the peripheral extremities of the nerves during dentition, or by worms in the alimentary canal, or by vitiated secretions, or a torpid liver. The symptoms here indicated are by some persons denominated fever, some epithet being usually added for the purpose of indicating its source or its nature ; hence the terms gastric, irritative, and hydrocephalic fever. The most expressive term that can be employed is that devised by Dr. Nicholl, " sensitive erethism." It is distinct from inflammation of the brain, of which it is frequently the precursor; and according to individual pecu- liarities or other modifying circumstances, it may end in cerebritis, meningitis, or that modification of the latter called hydrocephalus : and this ter- mination is but too often unexpected by the prac- titioner, whose attention has perhaps been directed to secondary indications and minor effects, whilst the erethismal state of the brain has crept on un- heeded. The condition here indicated cannot be supposed to exist unaccompanied by an increased flow of blood through the cerebral vessels, or in other words, an increase in their degree of tension; and as the tension may vary from a slight degree of fulness to the greatest of which the vessels are susceptible, such a state of local determination of blood will soon end in inflammation if not sub- dued by proper means. The actual inflammatory attack is generally ushered in by headach more or less violent, (the pain being referred to the temples, the vertex or forehead, sometimes to the 306 BRAIN, (INFLAMMATION OF THE ) — [MENIN GITIS.] occiput and base of the skull,) by intolerance of light: heavy and suffused eye, with quick pulse, are also attendants; so, in many instances, is vomiting. In adults, particularly those who have suffered much from mental disquiet, spasmodic twitchings are sometimes perceived, not unlike those which arise from slight electric shocks. In children and very young persons it frequently commences with a sudden and long-continued convulsion without any previous warning. After a while the convulsive movements cease, a remis- sion takes place, and the patient appears free from complaint for one or more days, when a second attack occurs, which may terminate in coma and youth at school, who was frequently accused of feigning illness. His countenance was natural, pulse not at all excited, nor did he complain of pain. The medical attendant ordered him to get out of bed and dress himself. This he submitted to very reluctantly; he went towards the fire-place, tottering as he walked, and sat down resting his head against the chimney-piece. So convinced were all present that he but feigned illness, that he was chastised. He died soon after, when the reality of his illness was ascertained by examina- tion ; a considerable degree of effusion of serum and coagulable lymph being found beneath the arachnoid membrane. This form of disease Cm- death. Some instances have been cited in which ! veilhier calls " meningite sous-arachnoidienne no remission occurred, insensibility supervening on the convulsion, and death in thirty-six or forty- eight hours. Martinet indicates three stages of the disease, each accompanied by a distinct group of symptoms. The first comprises the period of cerebral excitement and increased sensibility above noticed ; the second is the stage of re-action, or more properly that in which the cerebral irritation is propagated to the muscular system, and other systems in immediate dependence on the brain ; hence it is characterised by restlessness and con- vulsions, delirium, oscillations or commencing dilatations of the pupils : its duration varies from two or three days to a week, or perhaps two ! comateuse,-" and as he has met with several instances of it, he is disposed to come to a con- clusion the very opposite to that which other pathologists have adopted, inasmuch as when the meninges over the convexity of the hemispheres is inflamed, it is, according to his experience, cha- racterised by stupor gradually increasing to coma, whilst headach, with increase of sensibility, deli- rium and convulsions, are strangers to it. [Of late years, the formidable disease of the encephalon, that occurs so frequently in young children, and is generally called hydrocephalus acutus, has been regarded as tubercular meningi- tis,- or, in other words, as a deposition of tubercu- weeks. It is not undeserving of notice, that when \ lar granulations on the under surface of the cere- the arachnitis is seated on the convex surface of the cerebral hemispheres, delirium sets in very early, and becomes the prominent and characteris- tic symptom ; whilst if it occurs at the under surface and base of the brain, coma is the more usual attendant, and sets in early. The third stage is that of collapse ; being marked by loss of sense and motion, by paralysis, local or general, and coma; its duration varies from a few hours to three or four days. A considerable number of cases do in fact exhibit these regular steps and gradations of change during their progress; but we frequently observe the state of collapse and of excitement to co-exist; each of course being par- tial in its extent Thus one arm may lie motion- less by the side, whilst the other is convulsively agitated; and the muscles of the eye-lids may be paralysed, whilst those about the mouth are con- vulsed. Again, the first stage of the disease is bral layer of the arachnoid, which is essentially strumous in its character : and many cases are, doubtless, of this nature. (See Hydrocephalus.)] Morbid Anatomy.—After having been the sub- ject of inflammation, the membrunes present vari- ous changes dependent either on the duration and intensity of the attack, or on the frequency of its recurrence ; but all of them are referable to the following heads, namely, simple redness of the arachnoid; thickening and opacity, with increased firmness ; serous effusion beneath or upon it or into the ventricles ; puriform, or sero-purulent exudations; false membranes; increased vascu- [ larity and thickening of the pia mater. The ! redness of the arachnoid varies in extent and de- gree, and is usually confined to a few points on the convexity of one or both hemispheres, or at the base of the brain. It requires much care to distinguish this state of the membrane from one not in all cases ushered in either by pain or con- that closely resembles it, and in which the pia vulsions, by vomiting or fever. A state the very opposite to this sometimes presents itself. Thus Cruveilhier details the case of an elderly medical man, who, after some fatiguing employment, sud- denly became oblivious, looked stupid, could not answer questions, and seemed apoplectic : he was treated accordingly, but without relief; he still remained comatose, passed urine involuntarily, but retained the power of moving his limbs, though the left side seemed weakened. After death, serous effusion was found beneath the arachnoid membrane, extensively diffused over the brain and cerebellum, mixed with albuminous flocculi or Sakes of false membrane. This would be con- sidered as a case of serous apoplexy were it not for the effusion of lymph and false membrane. Another case was considered a feigned disease, so few indications of ill health, much less of cerebral mater is minutely injected, and at the same time adherent to the arachnoid. To determine whether the redness exists in the arachnoid or only in the vessels of the pia mater, a part of it should be cautiously raised from the surface of the convolu- tions, and gently scraped with a scalpel, or ex- posed for a few minutes to a slight current of water ; if the membrane is really inflamed, the colour will be found persisting, as if it were dyed into it; if the membrane is not inflamed, its natu- ral transparency will be restored. The alteration most commonly observed in the arachnoid is that it becomes opaque and whitish. In proportion as its transparency is diminished, its density and tenacity increase ; so that it is easy to detach it from the surface of the brain. These changes are seldom, if ever, general; they are usually confined to some parts on the upper surface of the heini- inflammalion, did it present. It was that of a j spheres, or at the base. In most cases there is no BRAIN, (INFLAMMATION OF THE) —[ME NINGITIS.] 307 appreciable increase of thickness, the membrane being merely a little opaque, and of a milky hue. This condition of the arachnoid is almost invaria- bly accompanied by an effusion of serous fluid, either upon its free surface, beneath it, or into the cavity of the ventricles. The effusion varies in quantity, being sometimes not more than a few drachms, and in other instances amounting to several ounces. It is usually limpid, particularly when contained in the ventricles; but occasionally opaque or milky, and mixed with albuminous flocculi or shreds of lymph if an exudation of false membrane exist at the same time. When the effusion is beneath the membrane, this is ele- vated along the sulci which separate the convolu- tions, and presents a gelatinous appearance, as if it had suffered a change of structure ; but if an incision is made along the surface, the fluid can be made to exude, and then the membrane subsides to its original position, and exhibits no other change except that of being a little opaque and thickened. Dr. Abercrombie notices a modification of this disease, remarkable from its rapidity and from simulating hysteria, or even mania ; although on examination it presents merely a highly vascular and injected state of the pia mater, complicated in some instances with slight subserous effusion. It commences with depression of spirits, to which cheerfulness soon succeeds, but finally passes on to delirium. The patient's manner is hurried ; he talks rapidly, wandering from one subject to another. Obstinate watchfulness exists through- out ; the pulse is small and rapid ; the counte- nance pale and expressive of exhaustion. The treatment is founded on these circumstances. Stimulants cautiously given afford relief, while depletion aggravates the evil, or produces hut a temporary alleviation. Chronic Meningitis.—Meningitis is in many instances so slow in its progress as to assume the chronic form. The disease is then characterised by^ a different train of symptoms. According to Bayle, delirium and progressive parajysis are the constant attendants of chronic meningitis. The delirium is at first partial; it is a monomania with weakness of intellect; but, after a time, it passes on to maniacal excitement, and finally subsides into confirmed idiotcy. The paralysis in those cases does not exhibit a total privation of sensation and motion in any particular part of the body ; it is at first slight, but gradually increases, and extends to the whole'muscular system, ren- dering the gait feeble and vacillating, and ulti- mately destroying the power of motion. It is remarkable that the diminution of sensation is not proportioned to that of motion. Spasmodic move- ments, with contraction and rigidity of the limbs, sooner or later set in ; and, finally, epileptic at- tacks, which terminate in fatal apoplexy. Besides the injection and thickening of the membranes, and the serous and albuminous effu- sions presented by the more rapid cases, the free surface of the arachnoid is found studded with minute conical granulations, or flocculi, so as to lose its smooth and polished appearance. Conti- guous parts of the membrane are also occasionally found connected by bands of false membrane; this most frequently occurs at some point of the inner flat surface of the hemisphere, where it is in contact with the falx major. The investing and reflected parts of the membrane are also found closely adherent along the angle formed by the inner and upper sides of the hemisphere, where the superficial veins enter the longitudinal sinus. In this situation the surface of the arachnoid is found rough, and studded with small rounded or irregular masses of a greyish white colour, which are sometimes called glandulse Pacchioni. These productions do not exist in early infancy, or in the healthy condition of the organ ; they appear to be an albuminous exudation, the result of chronic inflammation. In many cases the membranes are adherent to the subjacent cerebral substance, which is found altered both in colour and consistence. [Of 151 cases, observed at Charenton, 65, accord- ing to M. Andral, (Pathologie Interne,) lasted from a month to a year; 81 from one to six years; and 5 from six to twelve.] Causes___Meningitis is a frequent consequence of injuries of the head, of fractures, concussion, or even wounds, of the scalp. It not unfrequently happens that a wound of the head heals rapidly, and that the patient returns to his usual occupa- tions, thinking himself quite well ; but after ten or fourteen days he begins to feel pain in the situa- tion of the wound, which gradually increases in intensity ; and in a very short time all the symp- toms of cerebral inflammation become manifest. A child may suffer serious injury from a fall, and as all mention of the accident is suppressed by his immediate attendant, it escapes the notice of others, and no ill effects follow perhaps for a week or two: the child then, however, loses appetite, becomes restless and irritable ; febrile excitement, delirium, and convulsions succeed, and too often are the precursors of a fatal termination. In such cases, the real cause of the disease not being suspected, it is generally attributed to the irritation arising from dentition or worms; but examination after death shows that it is not merely a sympathetic disturbance, there being abundant evidence of active meningitis. In the list of causes should also be included depressing passions ; sudden fright, or unexpected disappointment; violent emotions ; immoderate indulgence of any sort, particularly in the use of spirituous liquors ; the suppression of cutaneous eruptions, and habitual evacuations or discharges; insolation (coup de soleil) in warm climates ; de- position of bone in the dura mater ; tubercle de- veloped in the cerebral substance, and extending to the circumference of the hemisphere, so as to become a mechanical irritant to the membranes. Such are the exciting causes of meningitis; but there are predisposing circumstances which con- fessedly render some persons more liable to it than others. One class of persons consists of those who possess what is termed the apoplectic consti- tution, indicated by a large head, short neck, and sanguineous temperament; the other class exhi- bits evidences of the lymphatic temperament, together with considerable cerebral development indicated by precocious talent Such persons in early life are very liable to attacks of meningitis, which terminate in serous effusion. Sex also seems to be a predisposing cause, or rather the peculiar pursuits and habits of the sexes; for BRAIN, (INFLAMMATION OF THE)-[CERE B RITIS.j 308 males are more liable than females, according to Martinet, in the proportion of three to one. All ages are liable to this affection, but not equally so: of one hundred and sixteen cases recorded by the author just cited, twenty-nine were under fifteen years, forty-four from fifteen to thirty, thirty-eight from thirty to sixty, and five from sixty to eighty. These results, it should be remembered, are taken | from hospital practice, in which the great majority of patients are adults. In private practice the proportion of cases under puberty is much greater than that here stated. The ordinary duration of acute meningitis is from seven to ten days, but death may occur on the third or fourth ; few cases are prolonged beyond the twenty-fifth or thirtieth. [Chronic meningitis has been rarely seen in infancy. It is also uncommon between the ages of 20 and 25; but is more common between 25 and 30 ; and attains the maximum of frequency at from 30 to 50. As in insanity, a predisposi- tion to it would seem to be laid in organization, for it appears in some families more than in others, and more commonly in the children of parents who have suffered by it. It has been induced by powerful emotions, and it is affirmed by the abuse of alcoholic liquors. (The writer's Practice of Medicine, 2d edit. p. 180: Philad. 1844.)] The treatment of meningitis will be included in the subsequent article, on inflammation of the substance of the brain. T qitai„ II. Inflammation of the substance of the BRAIN (Cf.RF.BIIITIS). We find very little information on the subject of inflammation of the substance of the brain, as a distinct and separate disease, in the early records of medicine. It has scarcely obtained a separate place in any of the nosological arrangements; every variety of inflammation, both of the brain and its membranes, being generally classed under the head of phrenitis. Bonetus and Morgagni are among the first writers who make any men- tion of the morbid alterations of the, brain arising from inflammation ; but they give no very distinct history of the symptoms, being satisfied, in gene- ral, with naming the diseases : many of their observations, indeed, are evidently taken from casual examination of bodies in the dissecting- room, and therefore afford very little satisfactory information. Sauvages sets down loss of sleep, headach, subsultus tendinum, and convulsions, as symptoms of arachnitis, and low delirium as that of encephalitis. Cullen includes all the inflam- matory affections of the brain and its membranes under the head of phrenitis, stating his inability to distinguish them from each other; and the same course is followed by Frank. Pinel, in his Noso- graphic Philosophique, endeavours to draw a line of demarcation between inflammation of the mem- branes and that of the brain itself, but this attempt is altogether hypothetical: he, however, states that after ataxic fevers he has found injection, inflammation, and suppuration in the brain and ts membranes, and therefore considers them as he seat of the disease. Several other French writers have alluded to inflammation of the sub- stance of the brain as a concomitant of ataxic fevers. Dr. Mason Good, in his Study of Medi- cine, ranges inflammation of the brain under one species, which he terms empresma cephalitis ; and he makes out two varieties, one superficial inflam- mation, called meningea, phrensy or brain fever, and the other profunda, affecting the substance of the brain and lining membranes of the ventricles, to which he refers hydrocephalus acutus; but he merely follows other nosologists in his description of symptoms and causes. The first distinct ac- count given of that peculiar alteration of the brain called softening, and of its characteristic symp- toms, was by M. Recamier, physician to the Hotel Dieu, in Paris, who considered it as one of the terminations of nervous fevers. Several of his pupils, and more especially Lallemand, Rostan, Parent, and Martinet, have since pursued the in- vestigation of this interesting branch of pathology with considerable success, and have published valuable works on cerebral diseases. Nearly about the same period the attention of the profession in Great Britain was directed to this subject by Dr. Abercrombie, whose pathological researches on diseases of the brain are held in high estimation on the continent, as well as in his own country. Some separate cases of inflammation and suppu- ration of the brain are to be found in Dr. Baillie's excellent manual of Morbid Anatomy. He refers to Dr. John Hunter's account of softening of the brain in the Gulstonian Lectures, read before the College of Physicians in 1796, describing two forms of softening ; that which occurs in old age, and that which is combined with apoplectic effu- sion. A valuable addition has been lately made to our medical literature in this branch of pathology by the medical reports of Dr. Bright, whose splen- did plates of the diseased structure of the brain are admirably illustrated by a history of well-selected cases. It will be seen by this brief sketch of the information afforded in medical writings on in- flammatory affections of the brain, that it is only within our own times that our knowledge of these diseases has begun to assume a practical and sys- tematic character. Inflammation of the substince of the brain may be divided ihto general and partial, acute and chronic. The general inflammation is always acute. The partial inflammation may be acute or chronic. Inflammation of the brain sometimes commences suddenly ; this is not, however, the most ordinary case. It is generally preceded by a variety of premonitory symptoms ; and as the disease, when once fully developed, is very formi- dable, it is of the highest importance that the prac- titioner should be well acquainted with these symptoms. The most usual premonitory symptoms are, a general uneasiness and restlessness, with a ten- dency to congestion in the head; a sense of weight and fulness; occasional attacks of pain in the head, or of temporary apoplexy or epilepsy ; flushing of the face and increased heat of the head; drowsiness and vertigo; preternatural acute- ness of the external senses ; intolerance of light and optical illusions; contraction of the pupils, strabismus, or imperfection of sight; tinnitus aurium, or various other noises in the ear; con- fusion of thought; failure of the memory; mental excitement or depression, or some striking altera- tion in the habitual character and pursuits of the BRAIN, (INFLAMMATION OF THE) — [C ERE B RITIS.] 309 individual. In some cases there is little appear- ance of indisposition throughout the day, but the symptoms are aggravated at night: the sleep is uneasy or disturbed by alarming dreams, and in children there is often grinding of the teeth. Pains in the limbs and frequent cramps, general lassitude and muscular debility, are often felt, alternating with fits of shivering and feverishness; the digestive functions are disordered ; there is in general loss of appetite; often obstinate vomiting: the bowels are either irritable or torpid, the secre- tions being always unhealthy. The above symptoms precede either general or partial inflammation of the brain. Those which follow indicate more especially the invasion of partial and chronic inflammation. A long-conti- nued, fixed, and deep-seated pain in one part of the head ; pain, numbness, weakness, a sensation of creeping and tingling in one extremity or in one half the body ; or confined to one portion of the extremity : there may be numbness and loss of power in one finger only, or in one set of muscles. Sometimes the speech is affected so as to produce a degree of hesitation, stuttering, or indistinctness of pronunciation. Drowsiness, lan- guor, depression of spirits, are observed also more particularly in the chronic form of cerebritis. Some of these premonitory symptoms may have been present for weeks, for months, or even for a year, or for a longer period. The practitioner cannot be too deeply impressed with the import- ance of the discovery and due appreciation of the foregoing train of symptoms : many of them may be overlooked by the patient, unless his attention be called to them ; he attributes his ailments to nervousness, debility, rheumatism, gout, and any but the real cause. He is allowed, perhaps, to live well; his stomach is strengthened and his nerves are soothed; whilst the disease in the brain, which will certainly end in death, is suffered to pursue its course. I. General Cerebritis.—General cerebritis is always acute. Its symptoms have been divided into two periods : 1. the period of irritation or excitement; 2. the period of collapse. The symptoms which characterize the period of excitement are, intense pain extending over the greater part of the head ; great excitement of the cerebral functions ; violent delirium ; pre- ternatural acuteness of both the external and in- ternal senses; intolerance of light; brightness, red- ness, wildness, or protrusion of the eyes ; contrac- tion of the pupils; tinnitus aurium; flushing of the face ; throbbing of the temporal arteries ; parox- ysms of general convulsion ; rigidity of some of the muscles on one or both sides of the body in the interval of the paroxysms. There are also severe shooting pains in the extremities, greatly increased by extending them ; twitchings of the muscles of "the face ; rolling of the eyes ; quick, suspirious, and irregular breathing; rapid, full, and hard pulse; subsultus tendinum ; red and dry tongue, either tremulous when protruded, or in violent motion, pushing out the cheek, or forcibly thrust out of the mouth; great thirst; occasionally severe vomiting, especially in chil- dren ; scanty and high-coloured urine. The pa- roxysms of convulsion are always attended with an exacerbation of the symptoms. The respira- tion is hurried, and the pulse rises suddenly forty or fifty beats in a minute. When the convul- sions subside, the pulse and respiration become comparatively slow and feeble. The symptoms just enumerated may last from twelve to forty-eight hours, or more, when they are succeeded by others of an opposite character, which constitute the second period, or that of collapse. The headach is now no longer com- plained of; the delirium gradually passes into stupor and coma ; the preternatural acuteness of the senses is succeeded by obtuseness and insen- sibility ; the convulsions subside into general muscular relaxation, and more or less complete paralysis succeeds. The pupils become dilated and motionless; the eyes sunk, pale, and dim ; there is sometimes strabismus, or deafness ; the pulse is rapid, small, unequal, or intermittent; there are frequent rigors, the skin afterwards feeling cold and covered with a clammy sweat; the face is pale, sunk, and cadaverous ; the respi- ration is slow, or irregular and stertorous. When the patient lies senseless on his back, and swal- lows with difficulty, the fatal issue is not far dis- tant. There may be several alternate paroxysms of excitement and collapse, until the patient finally sinks into a state of coma, which soon ends in death. A great resemblance is apparent between the preceding delineation of general cerebritis and that of arachnitis. A more strongly marked and permanent degree of rigidity in the muscles on one side of the body is, however, believed more particularly to indicate cerebritis. The disease may have been preceded by some of the premo- nitory symptoms, and have set in with headach and delirium, terminating in coma ; or the inva- sion may have been sudden, and attended by a violent paroxysm of convulsions. In the former case, it is probable the inflammation had its origin and principal seat in the brain; in the latter, that it was confined to the membranes. The diagno- sis between the two cases is, however, extremely difficult; the one generally giving rise to or ter- minating in the other. The symptoms are of course variously modified, according to the extent and intensity of the in- flammation, which may occupy one half of the brain and extend in depth, or may be spread over the surface, or affect several isolated portions in both hemispheres. General cerebritis in most instances proves speedily fatal; the inflammation of a large por- tion of the brain being incompatible with the pro- longation of life. In the majority of cases on record, death occurred within a week; in some within twenty-four or even twelve houTs, the in- flammation scarcely ever going beyond the first This form of inflammation of the brain may exist in combination with inflammatory affections of other organs, and occasion modifications in their symptoms demanding close altention. The intense pain arising from inflammation in the abdominal and thoracic viscera, when such a com- bination exists, may not be felt by the patient, although the inflammation is pursuing its course unabated. This has sometimes led to the danger- ous mistake of believing a disease removed which 310 BRAIN, (INFLAMMATION OF THE) —[CEREBRITIS.] was only masked. Hippocrates was acquainted with this source of delusion, for he says that whenever a patient suffers and does not complain, mens xgrotat, the mind is diseased. We have seen serious consequences follow this deception in cases of continued fever with head symptoms. In such cases, therefore, the practitioner cannot be too much on his guard ; and the very circum- stance of the denial of pain, without amendment in other respects, should induce him to ascertain, by manual examination and every other means, the true condition of the principal viscera. Par- ticular attention should be paid to the region of the bladder; as from insensibility, the bladder ^ets over-distended and partially paralysed ; the resistance of the sphincter vesica? is overcome ; the urine dribbles out by drops, and the patient is supposed to suffer from incontinence, whilst he is, in reality, affected with retention of urine. The same insensibility is the cause of the great difficulty sometimes experienced in exciting vo- miting in cerebral affections. II. Partial Cerebritis. — Partial inflamma- tion of the substance of the brain may be acute or chronic.; the disease assuming a variety of forms according to the severity, extent, and seat of the inflammation. Its invasion is generally slow, and preceded by some of the premonitory symp- toms, which are, in fact, the mere signs of that state of local congestion and irritation which im- mediately precede inflammation. We shall first give a description of the principal forms of the disease, and then take a general view of the symptoms. 1. In partial cerebritis, the individual is at- tacked with fixed, deep-seated pain in the head, vertigo, dimness of sight, hesitation of speech, sensation of tingling, pain, cramps or weakness in one or other of the extremities ; one of the limbs suddenly giving way during exercise, so as to occasion stumbling ; or the walk is unsteady, like that of a drunkard. The general health is, at the same time, more or less impaired. These symptoms may have gone on for a certain time without fever or affection of the intellect ; so that no serious alarm has been excited till the patient is suddenly seized with an attack of coma and insensibility. He may recover from this in a few minutes or hours, when one arm or leg, or even one half the body is found paralysed. The para- lysed limbs are almost always first in a state of permanent rigidity, and more or less bent, in consequence of the flexor musdes having greater power than the extensors. Lancinating pains are also felt in the muscles, and much increased i y extension. From all these s\ mptoms the individual may so far recover as to be able to leave his bed, the limbs continuing paralysed; in other cases, some degree of stupor and mental weakness remains, with a peculiar frowning or vacant expression of countenance; the patient still, however, showing some signs of intelligence when roused. Several of the external senses may be affected; the sight of one eye, for in- stance, may be impaired or destroyed : or there may be dilatation and insensibility of one pupil, and contraction of the other, or strabismus. In like manner, the sense of hearing may be imper- fect, or wholly lost There may be symptoms of low fever, with delirium ; but there is seldom any violent re-action. The assemblage of symptoms just described constitutes the first period of the disease, or that of cerebral irritation. After various intervals, a second or even a third attack of coma is experienced, and the patient either dies suddenly or sinks under gradual ex- haustion. As the disease advances, a change takes place in the state of the paralysed limbs; the rigidity, gradually subsiding, is succeeded by relaxation, flaccidity, and complete paralysis. This marks the second period of the disease, or that of softening and complete disorganization of the por- tion of brain affected. 2. In many cases the paralysis of the limbs is at first only partial; a certain degree of motion is preserved, but there are convulsive spasms, generally of short duration ; and after alternate attacks of this description, the paralysis gradually becomes complete. This order of the symptoms generally corresponds with the progress of the inflammation from the first stage, or that of excite- ment, to the second, or that of softening and sup- puration. When the inflammation spreads from the brain to the membranes, constituting the combination of partial cerebritis and arachnitis, the side of the body not paralysed is generally affected with pa- roxysms of convulsion, in which sometimes the paralysed parts themselves participate. These diversities in the affections of voluntary motion will be more particularly considered in the gene- ral review of the symptoms. 3. The order in the progress towards complete paralysis just described is sometimes reversed; there being at first sudden and complete resolu- tion of the muscles; and the spasmodic rigidity with convulsions only appearing some time after. It not unfrequently happens that, if the conges- tion be violent and sudden, and the blood-vessels weak or diseased, extravasation of blood takes place in the brain, either by rupture of a blood- vessel or exudation, before the inflammation has had time to set in. Instead of a gradual loss of voluntary motion, with spasmodic irritation of the muscles, there is then a sudden and complete abolition of muscular power in some regions of the body, and a state of perfect paralysis, in con- sequence of the sudden destruction of a portion of cerebral substance, and of the pressure exer- cised by the clot of blood. This difference in the mode of attack forms a good line of distinction between sanguineous apoplexy and cerebritis, in the great majority of cases. After a certain time, however, the clot of blood irritates the surround- ing cerebral substance, and excites inflammation: pains, cramps, and convulsions are then experi- enced in the relaxed and paralysed muscles, so that they sometimes become perfectly rigid : this constitutes the form of disease known as consecu- tive cerebritis. Apoplexy and cerebritis are dis- eases which frequently have a common origin, viz. cerebral irritation and congestion, and are only modified in their progress by accidental circum- stances ; though in apoplexy it is too often the custom to consider only the extravasated blood, which is a mere effect, and to overlook the pre- vious morbid condition of the brain which was the cause of the hemorrhage. The invasion of BRAIN, (INFLAMMATION cerebritis is generally slow, and characterized by premonitory symptoms; the course of the disease is marked by great irregularity, by frequent exa- cerbations of some of the symptoms, and by de- ceitful remissions. Apoplexy, on the contrary, takes place more suddenly, and often without any very decided premonitory symptoms; the paralysis is more complete from the beginning, and the progress of the disease less variable. Apoplectic extravasation of blood sometimes takes place in the advanced stages of cerebritis, by the bursting of a vessel in the centre of the softened mass of brain: a sudden attack of coma is generally the consequence. The pre-existence of the symp- toms of cerebritis will afford a sufficient distinc- tion of such a case from common apoplexy. 4. Partial cerebritis is sometimes acute, and the inflammation passes rapidly through its different stages, as may easily be conceived in an organ so vascular and highly organized as the brain. The patient may in that case sink under the first attack of coma, and the disease will be generally found to occupy a considerable portion of the brain. Even when the disease is limited to a small extent, it may prove rapidly fatal, in consequence of the portion of the brain it affects; as, for in- stance, when its seat is in the medulla oblongata, or contiguous to the arachnoid and pia mater. It is proper also to remark that the extent of the in- jury arising from disease of the brain is very much in proportion to the rapidity of its develop- ment : a very slight degree of pressure, if sud- denly applied, is capable of creating violent con- stitutional disturbance; this will account for the disproportion sometimes observed between the severity of the symptoms and the extent of the disease. When it commences by an attack of paralysis, without coma, delirium, or any serious affection of the head, the inflammation is com- monly at first slight, and seated near the origin of the spinal cord. 5. There is another form of cerebritis, in which the inflammation is of a more chronic character; the disease more slow, obscure, and variable in its progress, and the paralysis of the muscles neither preceded nor attended by symptoms of irritation. The disease may commence with a slow and gra- dual loss of power, at first limited to a single region of one of the extremities, or to a single set of muscles, and without pain, cramps, or ri- gidity ; the tongue may be affected, or the sight of one eye; or there may be slight distortion of one side of the face: the paralysis gradually creeps on, until it has invaded successively the upper and then the lower extremity, on one and sometimes on both sides of the body. The disease is not attended in its progress with any general re-action, the onlv appearances of disturbed health, for a length of time, being symptoms of debility and decay, both bodily and mental; until, at the end of several months, or perhaps longer, the patient is suddenly seized with coma and convulsions, or else sinks under gradual exhaustion. There are sometimes, however, deviations from this uniform course, and the progress of the disease, although slow, is marked by occasional affections of the head and symptoms of general irritation. This is the form of disease which has appropriately enough received the appellation of creeping palsy. OF THE) —[CEREBRITIS.] 311 It usually proceeds from a low state of inflamma- tion of the brain, commencing in a small portion, and gradually extending to a larger one ; the in- flammation generally continues for a consideiable time in the first stage; it may prove fatal in that stage, with symptoms of coma and convulsion; or pass on to softening and abscess, with their usual consequences. This is the form of disease which usually attends that variety of white soften- ing called simple softening, in which the arteries are frequently found diseased. The disease also sometimes terminates in permanent induration of the portion of the brain affected. A good many cases of partial induration of the brain have been related by Morgagni, Baader, Abercrombie, &c. &c.; they were all of a pro- tracted nature, and characterized by a degree of irregularity and intermittence in their symptoms, which closely resembled those of organic disease. The disease in some cases assumed so completely an intermittent form as to mislead with regard to its real character. This tendency to periodicity is of frequent occurrence in all the chronic forms of cerebral inflammation. There is a variety of chronic cerebritis peculiar to lunatics, who, after being affected for a consi- derable time with acute mania, have gradually . sunk into imbecility and idiotcy. The paralysis is not confined to one region, but extends to the whole muscular system; it is at first slight, and only indicated by a general tremor and debility; a sluggishness and vascillation in all the motions; fatuity, and sometimes low delirium : these symp- toms gradually increase; the sensibility becomes I obtuse, and the disease generally terminates in paralysis with spasmodic rigidity, or in apoplexy. The appearances after death are—redness, soften- ing, sometimes atrophy, and a granulated appear- ; ance of the cortical substance on the whole sur- I face of the hemispheres; chronic inflammation of the membranes, which adhere firmly to the surface of the brain; serous effusions; an indu- ! rated state of the medullary substance, sometimes with partial softening. 6. Partial cerebritis is sometimes connected , with disease of the cranial bones. Desault, Aber- I crombie, and others, have recorded some interest- ing cases of a disease of the inner table of these bones, the outer table remaining perfectly sound, so that there was no external indication of the disease. The symptoms were characterized by fixed, intense, and deep-seated pain in the head ; a disturbed state of health; violent delirium; drowsiness, double vision, and coma. The dis- ease seems to have been the result of a very slow inflammatory action, lasting in some cases for many years, and gradually destroying the bone by caries. On dissection, the inner table of the bone has been found destroyed; the rough can- cellated structure covered with lymph, or adhering to the inflamed and thickened dura mater; the membranes adhering to the brain, which was in- flamed and softened. In some cases the bone has j been reduced by absorption to a transparent thin- i ness ; the dura mater being also partly absorbed, and the brain livid and indurated. In others, after a blow on the head, a small portion of the cranium has been completely absorbed without any ulcerating process, leaving the brain covered 312 BRAIN, (INFLAMMATION OF THE) — [CEREB RITIS.] only by the healthy skin. Two instances of this kind are related by Mr. Howship and Mr. Wil- j mar: in one of them there was hemiplegia ; both i patients survived, but the deficiency of bone was not supplied. More generally, however, both plates of the bone and the intervening diploe are affected with chronic inflammation, which brings on a variety of morbid changes; such as the for- mation of bony tumours, or ridges, caries, exfolia- tions, or excessive thickening of the integuments: these finally lead to inflammation of the brain and its membranes. Saviard mentions the case of a woman in the Hotel Dieu, in whom, in con- sequence of an injury of the head from a fall, successive exfoliations of both tables of the cra- nium took place to such an extent that the pieces, when put together, resembled the skull-cap as it is sawn off in dissection: this process occupied two years, at the end of which she was dismissed in good health, but with the upper part of the brain covered only by integuments. There is a variety of the disease beginning in the pericranium, which is often accompanied by very urgent symptoms.; it is a chronic inflamma- tion of the periosteum, with thickening, indura- tion, and sometimes suffusion of pus. The cor- responding portion of dura mater is inflamed and thickened, and the disease extends to the brain ; the intervening bone in some cases remains healthy, in others it is also diseased. It is at- tended with intense, fixed pain, and there is some- times such exquisite tenderness in the part, that the slightest pressure brings on syncope and con- vulsions : there may be also various affections of the sight, hearing, speech, and intellect, and various forms of paralysis or convulsions. Relief has generally been afforded by deep incisions down to the bone, and by exciting and keeping up suppuration. It may be necessary in some cases to repeat the incisions. In some instances related by Mr. Crampton, the disease appeared as a circumscribed tumour: in one, the swelling spread considerably, and was accompanied by erysipelas; more generally, however, there is no visible tumefaction. One of the distinguishing features of these va- rious forms of disease is, their very slow progress, owing to the low state of inflammation of the parts affected; they have been known to last for years, and even during a great part of a patient's life; and an apparently very slight degree of in- flammation has in some cases given rise, for a considerable length of time, to the most urgent symptoms. The inflammation has been excited in some instances by an injury so trivial as to escape the patient's attention; though it should be kept in view that it is not always confined to the part which was the seat of the injury, but has sometimes a tendency to spread over the cranium. It may also occur spontaneously, in which case it is occasionally connected with a syphilitic taint, or scrofulous diathesis. In chronic otitis there is a great tendency in the inflammation to spread from the inner ear to the brain: suppuration of the brain has also, in some cases, made its way out by the ear; and it is generally remarked, that when the suppuration from the ear is checked or suppressed, this is al- most immediately followed by symptoms of acute cerebritis ; and again, that as soon as the suppu- ration of the ear is restored, the symptoms of cerebral inflammation disappear. This affords a striking proof of the effects of pressure, and points out the great caution which is required in the treatment of otitis, to prevent the extension of the disease to the brain. 7. We shall conclude this account of the differ- ent forms of cerebritis with some general remarks on the progress of the disease. It sometimes pursues its course without intermission, either to a favourable or fatal termination, with only occa- sional exacerbations of the symptoms. At other times there are well-marked remissions, with an apparent amendment When cerebritis passes from the first stage of inflammation, or that of excitement, into the second or that of softening, there may be such a remission of the febrile symptoms, although the paralysis remains, as to excite hopes of recovery. This should not, how- ever, deceive the practitioner, as the improvement is often merely delusive, and soon followed by repeated relapses. There are occasional instances of the symptoms assuming a remarkable periodi- cal course, and returning at regular intervals. In one case, after a wound in the head, the patient was seized every evening with a paroxysm of delirium, succeeded by stupor; he died in the course of the fifth paroxysm ; and on dissection there was found extensive inflammation of the membranes, and suppuration of the brain. In another case, in which the paroxysm set in at the same hour, lasted exactly the same time, and re- curred every second day, the symptoms were those of well-marked cerebritis, and there was complete apyiexia during the intermissions; the arachnoid and pia mater were found inflamed, and there was a large undefined abscess in the middle lobe of the right hemisphere. These cases had been mistaken for pernicious intermittent fever, and treated by bark. It is not easy to explain satisfactorily the cause of these regular exacerba- tions and intermissions; they are probably the effect of some sudden congestion in the brain, aggravating the symptoms. There is a well- known tendency to periodicity in all the affections of the cerebral and nervous system ; the formation of pus in every vital part is also known to be at- tended with occasional rigours and paroxysms of hectic fever. This tendency to intermittence and periodicity is most frequent in chronic cerebritis. A number of interesting observations on cere- britis in horses have been made by M. Dupuy, professor in the Veterinary College of Alfort, near Paris. The spinal marrow was found more frequently affected than the brain ; which is easily accounted for by its being much larger in these animals, in proportion to the brain, than in man; and by its being also much more exposed to suf- fer from violent muscular exertion. The morbid alterations after inflammation corresponded in every respect with those observed in the human subject: the symptoms attending the disease were — tremor of the extremities, weakness, convul- sions, tetanic stiffness of the muscles of the neck, jaws, and more especially of the hind-quarters, which were the first to be affected with paralysis. One remarkable symptom was, a disposition in the horses thus affected to place the head against BRAIN, (INFLAMMATION OF THE) — [CEREBRITIS.] 313 the wall and to push forward with all their force, I so as even to break through or overthrow parti- I tions. They were observed to continue in this attitude, with a kind of tetanic stiffness, for above an hour, until the paroxysm of spasm subsided, when they dropped down from exhaustion. The disease always ended in paralysis, coma, and con- vulsions. It is one of the forms of disease known in this country by the name of staggers. General review of the symptoms.—We shall complete the history of the different forms of cere- britis by taking a general review of the leading symptoms, pointing out at the same time the dif- ferent pathological conditions of the brain with which they seem to be connected; so far at least as is practicable in the present state of our know- ledge. When the inflammation occupies at the onset a large portion of the brain, we have seen that it is generally complicated with meningitis, and cha- racterised by disturbance in all the vital functions; that we may recognise in the symptoms a period of high excitement, and one of corresponding depression ; and that it runs its course speedily, either to a favourable or fatal termination. When, however, a smaller portion of the brain is engaged in inflammation, as in partial cerebri- tis, the course of the disease is seldom so rapid ; its invasion is more gradual, and preceded by symptoms of irritation in some of the organs of voluntary motion, sensation, or intelligence ; and in the more advanced periods of the disease the functions of some of these organs become consid- erably impaired, or completely abolished. We have stated that, when partial cerebritis is fully established, one of the most constant symp- toms of the first period is paralysis of voluntary motion, with spasmodic rigidity of the muscles, producing permanent flexion of the affected limb. The limb is sometimes considerably bent, and its extension is attended with severe muscular pains; tljis spasmodic action generally shows itself first in the arm, in which it is always greatest, and then extends to the inferior extremity. When the muscles of the face partake of the spasm, the mouth is drawn towards the paralyzed side ; the eyelids are closed by the contraction of the orbic- ular muscle, so that some stiffness is felt in at- tempting to open them. But in the more ad- vanced stages, when the paralysis becomes com- plete, and the muscles are relaxed, the mouth is drawn by the healthy muscles to the side opposite that paralyzed. The eye continues closed, but it is from the dropping of the eyelid, in conse- quence of the paralysis of the levator palpebral superioris. Convulsive rigidity and retraction of the mus- cles are sometimes observed in connection with meningitis; but it may be generally distinguished from spasmodic paralysis by several well-marked signs. There is no actual paralysis; and when the convulsive retraction intermits, the patient fully recovers the power of voluntary motion in the same manner as after the paroxysms of spas- modic rigidity in tetanus. This convulsive rigid- ity is scarcely ever limited to one region or to one side of the body, as in partial cerebritis, but affects a variety of parts at the same time on both sides. Another ground of distinction is, that the sensi- Vol. I. — 40 2 b bility remains unimpaired. In spasmodic paraly- sis the rigidity and loss of voluntary motion are permanent and the sensibility of the affected parts is more or less obtuse. The accuracy of these rules of distinction has been considered by some as still rather doubtful, and this is a point in the pathology of these dis- eases requiring perhaps further investigation. We are of opinion, however, that they are not without foundation. It is true that spasmodic paralysis is a very common symptom of chronic meningitis ; but it is equally certain that, if the brain be carefully examined, chronic inflammation of the membranes will almost always be found combined with inflammation and softening of the surface of the brain. These views are supported by the authority of Bayle, Laennec, Lallemand, Gendrin, and several other eminent pathologists. Spasmodic paralysis, with pain and other signs of irritation, is generally characteristic of the first stage of cerebral inflammation, or that of excite- ment : the disease sometimes terminates fatally at this period. When the inflammation, however, advances towards the second stage, or that of softening and suppuration, the rigidity and muscular contraction gradually lessen, until at last there is complete i paralysis. This condition of the muscles has generally been found in connexion with softening and disorganization of some part of the brain. An important difference exists, therefore, between the spasmodic and the complete paralysis : the first, being the effect merely of the compression and irritation of the cerebral substance occasioned by the great influx of blood in the first stage of inflammation, is capable of being removed, if we can only succeed in subduing the inflammatory action at an early period ; the second, arising from the complete destruction of a portion of cere- bral substance, is beyond hope of recovery, since there is yet no instance on record of the repro- duction of brain. When the paralysis is at first partial, and in- creases only gradually, the paralyzed muscles are sometimes affected with convulsive motions, gene- rally of short duration. This usually happens when the progress of the inflammation is slow, and the diseased portion of brain is partly in the first and partly in the second stage of inflamma- tion. When arachnitis supervenes on partial cere- britis, both sides of the body may be convulsed ; but in this case, when the paroxysms of convul- sion intermit, one side only remains paralyzed. Convulsions affecting both sides of the body at the same time may generally be considered symp- tomatic of inflammation of the membranes, rous- ing into inordinate activity the functions of the healthy brain, and thus exciting violent irregular action of the voluntary muscles. But, when the substance of the brain itself is extensively dis- eased, the power of voluntary motion is partially impaired or altogether destroyed. General con- vulsions may also be the effect of simple pressure or of nervous irritation; but in these cases the fever which attends arachnitis is altogether ab- sent. In some instances one-half of the body has been violently convulsed, whilst the other has remained perfectly motionless, as if dead : this has been observed to arise from the combination 314 BRAIN, (INFLAMMATION OF THE) —[CERE BRITIS.] of arachnitis with very extensive softening and destruction of one side only of the brain. In other cases both sides of the body have been af- fected with paralysis in succession ; this generally indicates the extension of the inflammation from one hemisphere to the other, but these cases of double cerebritis are not common. In chronic cerebritis we have seen the paralysis assumes a different character; its invasion and progress be- ing very slow and gradual, and not usually attend- ed with any muscular pain or spasmodic irritation. Inflammation and softening of some of the cen- tral parts of the brain (the corpus callosum, for- nix, and septum lucidum) do not occasion any paralysis. The paralysis in the latter stages of cerebritis frequently affects the organs of speech. In some cases there is great volubility of speech; this principally happens on the approach of delirium ; but more generally the utterance is slow and drawling: at first there may be only a slight de- fect or hesitation in pronouncing one letter or cer- tain words ; at other times the patient is affected with an entire loss of speech, either suddenly or by slow degrees. The loss of speech may pro- ceed from loss of memory alone, the tongue re- maining free; or the tongue and memory may be simultaneously affected. Paraplegia, which had generally been consider- ed as always the result of disease of the spine, has been observed by several writers to depend sometimes on inflammatory or organic affections of the brain alone, especially in adults. A paper will be found on this subject, by Dr. Baillie, in the Transactions of the College of Physicians, vol. vi., and one by Mr. Earle, in the Medico-Chi- rurgical Transactions for 1828. This subject will be more fully considered in the article Pa- ralysis. The explanation of paralysis and convulsions affecting the side of the body opposite to the dis- eased hemisphere of the brain, is to be found in the decussation of the nervous fibres in the ante- rior portion of the medulla oblongata. It takes place so invariably that it may be almost consid- ered as a general rule ; there are, however, seve- ral well-authenticated cases on record, of paraly- sis having occurred on the same side of the body as that occupied by the disease of the brain. M. Bayle, in the Revue Medicale for January 1826, states that he had seen two unequivocal cases of this description in his own practice, and relates eight similar cases taken from former writers ; three of them from Morgagni. A case in support of the same fact has been published by Dr. James Johnson, in the first volume of the Transactions of the Associated Apothecaries. Dr. Gall and other modern anatomists have distinctly shown that the decussation of the nervous filaments in the anterior portions of the medulla (corpora py- ramidalia) is not always complete, and that seve- ral of these filaments are sometimes continued from each crus cerebri along the medulla spinalis on the same side : this may afford some explana- tion of the cases in question, although it is not perhaps altogether satisfactory. It has been sup- posed by some that the decussation takes place in the corpus callosum ; but this appears without the least foundation. This subject has been discussed by Dr. Yelloly at considerable length, in a paper published in the first volume of the Medico-Chi- rurgical Transactions. Next to the affections of voluntary motion, loss of sensibility is one of the most prominent symp- toms of cerebral inflammation : the two classes of symptoms are generally combined, but seldom manifest themselves exactly at the same time. The paralysis of the skin usually appears later than that of the muscles, so that an extremity may have lost the power of motion, while it still preserves some degree of feeling. The sensibility, however, gradually decreases, until at last it be- comes very feeble or totally abolished. The arm is generally deprived of motion before the leg; and the loss of feeling follows in the same order. The loss of voluntary motion alone indicates a less complete degree of paralysis than when com- bined with loss of feeling. There are some inter- esting facts connected with the loss of feeling as well as with diminution of temperature, which we shall have occasion to consider more in detail in the article Paralysis. This account of the symptoms derived from the affections of voluntary motion and sensation has been deduced from a careful examination of a large body of well-observed facts collected by others, as well as from our own experience. It is necessary, however, to keep in mind that the ac- curate study of the symptoms in cerebral diseases is too often surrounded with many difficulties and sources of error. The patient is sometimes in the situation of a child, unable to explain his sensations, either past or present; the obtuseness or total loss of consciousness, preventing the free and full development of the symptoms, alters or completely conceals the true character of the dis- ease ; the absence, therefore, of any of the lead- ing symptoms, in one case, under such circum- stances, is not to be taken as a proof of their fal- lacy in every other. Several of the symptoms, spasms and convulsions for instance, may be sO evanescent as to escape superficial observation. An accurate knowledge of the comparative state of the different regions of the body with respect to sensation and motion is sometimes attended with great difficulty, and requires the most care- ful examination. We cannot always see the pa- tient in motion so as to judge of the exact degree of power he possesses over the different muscles ; we must then make him grasp or lift a body. The state of feeling and of heat in each region should likewise be accurately noted. We feel strongly convinced that numerous mistakes are committed in all these respects by a hurried and superficial observation; and we need no better proof of the truth of this assertion than the very imperfect manner in which many of the cases on record are reported, some of the most important facts being frequently altogether omitted. It is always of considerable importance to obtain, tinguish them from each other. The progress of the symptoms in organic diseases is very slow, irregular, and intermittent; very trivial circum- stances are sometimes sufficient to bring on attacks of cephalalgia, vertigo, temporary apo- plexy, or convulsion; such as quick exercise, hot rooms, sudden emotions, prolonged attention in reading or writing, a low position of the head ; in fact, every thing calculated to disturb and hurry the circulation in the brain. When this organ is already suffering from pressure, a very slight change in its circulation may suffice to give rise to the most alarming symptoms ; but these sub- side as soon as the momentary congestion is removed, and the patient then recovers every ap- pearance of his usual health. In some cases the symptoms entirely disappear for a considerable time, and then return with increased violence. The disease does not in general assume a de- cidedly active and regular character until the surrounding brain becomes inflamed; and the two forms of disease being then combined, the ordinary symptoms of cerebritis make their ap- pearance.* In chronic cerebritis, although in some instances the symptoms may be slow and irregular, they do not in general exhibit such sudden exacerbations or complete and protracted intermissions, nor are they aggravated by the same trivial cause. Cases, however, attended with much doubt and difficulty, may sometimes present themselves, especially when chronic cere- britis terminates in induration ; but it may be laid down as a general rule, which will materially assist in forming the diagnosis, that the very large majority of cases of primary cerebritis run their course in less than six months from the time of the full development of the disease ; whilst the great majority of organic diseases last beyond that time, and some even as long as several years. The tubercular diseases are those the course of which is most rapid, particularly *The late Dr. Wollaston died of an organic disease nf the brain, which there is good reason to suppose originated in slow chronic inflammation: we find it stated, in the post-mortem examination, that the optic thalamus of the right side was found converted into a tumour as large as a middle-sized lien's egg; towards the circumference, it was of a greyish colour, harder than the brain, and somewhat of a caseous consistence, but in the centre, of a brown colour, soft, and in a half dissolved state. We learn from Dr James Somerville, who attended Tiim, that he had suffered more or less for several years from a train of symptoms corresponding to those above described, and that he ultimately died para- lytic. Four years previous to his death iin 1823) he read before the Royal Society an ingenious paper on a pecu- liar defect of vision to which he was subject, and which, it is highly probable, was a symptom of the incipient dis- east* of the brain. I when there is active tubercular inflammation in i other parts of the body. Hypertrophy. — Several pathologists, and amongst others Laennec and Jadelot, have de- scribed an alteration of the brain connected with its acute diseases, which they term hypertrophy : this alteration appears to have been known also to Morgagni. Laennec observed it in persons | who had previously been supposed to be affected with hydrocephalus internus; also in epileptic children, and in others who had died of convul- sions. The following are its distinctive charac- ters :—the convolutions of the brain are crowded together and flattened ; the intervals between them disappear ; and it seems as if the mem- branes of the brain were too tight for it. After the upper part of the cranium has been removed, it is found difficult to make it fit on again, the brain appearing too large for the cavity of the skull; the substance of the organ is firm, contains but little blood, and appears remarkably dry when cut into; the ventricles are, as it were, effaced, and the various surfaces of the brain deprived of their ordinary moisture : in other respects the texture remains unaltered. The affection is most frequently general. Andral has however seen a case, in which the left thalamus was one-fourth larger than the right, which was of the natural size ; there had not been any particular symptom observed during life, that could lead to a suspicion of such a state of the parts. No instance of hy- pertrophy of the cerebellum has hitherto been published. In a few rare cases the enlargement of the brain has been carried to such an extent as to occasion an enlargement of the skull. A remarkable case is recorded in the Archives de Medicine, 7th volume, of a child of five years of age, who bad a head as large as that of a stout man ; the parietes of the cranium varied from a line and a half to two lines in thickness ; it was chiefly the hemispheres that were enlarged ; there had not been any peculiarity in the intellectual faculties ;—the death was owing to another acci- dental cause. The brain appears sometimes as if generally enlarged, when its vessels are over- distended with blood, in inflammatory fever, &c. This state must not be mistaken for the hyper- trophy just described. [See Condie, Practical Treatment on the Diseases of Children, p, 336 • Philad. 1844.] We shall briefly notice another class of morbid alterations of the brain, as being connected with its acute affections ; we mean those observed in lunatics. After acute mania, the cortical sub- stance on the whole surface of both hemispheres has been found deeply injected, and of an intense red, similar to that of erysipelas. In other cases of longer standing the membranes had contracted close adhesions to the brain; the cortical sub- stance was red and so much softened, that the membranes could not be removed without tearing it away with them ; it had also a granulated ap- pearance. In very old cases the convulsions have been found remarkably diminished in size; and this has seemed to arise from the atrophy of the cortical substance, which was reduced to a very thin layer, and of a pale dirty colour; there has been generally in such cases a serous effusion, as if to fill up the vacuum. The medullary sub- 324 BRAIN, (INFLAMMATION OF THE) —[CEREBRITIS.] stance has also been found to have undergone remarkable changes : it was in some cases highly injected, and of a marbled red colour ; in others it had experienced a surprising increase of density, being as tough and difficult to cut through as caoutchouc, and of a smooth shining white colour; and, lastly, it has been found softer than in health, and flaccid. A great quantity of serous fluid is sometimes found in the brain of old lunatics. We only notice these morbid appearances very briefly, in order to give a general view of every variety of change of structure produced in the brain by inflammation : they will be described more in detail in the article Insanitv. The different morbid appearances of which a description has been given may be summed up as follows :— 1. Increased vascularity; redness either dotted or uniform, no change of consistence or structure, no exudation of fluid or rupture of vessels.— Con- gestion. 2. Great increase of vascularity, intense dotted redness, spots of ecchymosis, with a striated ap- pearance and effusion of drops of blood, increased firmness.—First stage of inflammation. 3. Infiltration of blood, and softening of the cerebral pulp towards the centre of the inflamed portion. — Red softening. Infiltration of pus mixed up with the disorganized pulp. — Yellow softening. The red and yellow softening com- bined. 4. Serous infiltration of the cerebral pulp; softening of a milk-white colour, without vas- cularity.— White softening. 5. Increased formation of pus of various colours, the walls of the cavity lined with a membrane.— Undefined abscess ; encysted ditto. 6. Loss of substance on the surface of the brain or that of the ventricles.— Ulceration. 7. Infiltration of the pulp or its vessels with permanently concrete fluids; conversion into a more or less dense mass.—Induration. Diagnosis. — The diagnosis between arach- nitis, apoplexy, and cerebritis, having been al- ready fully considered in the general history of the disease, a brief recapitulation is all that will now be required. We have seen that the lead- ing features of arachnitis were the absence of premonitory symptoms; spasmodic and convul- sive symptoms on both sides of the body ; febrile excitement, without decided paralysis, followed by collapse. Those of apoplexy, sudden and complete para- lysis, without spasmodic symptoms at the begin- ning ; sudden invasion and rapid progress. Those of cerebritis, symptoms of irritation fol- lowed by spasmodic paralysis, only partial at first; the paralysis becoming complete as the disease advances; irregular exacerbations and remissions; well-marked premonitory symptoms. In laying down these general rules, it is fully admitted that, in the present state of our know- ledge, cases may occur, in which the diagnosis will be involved in doubt and obscurity. The distinction between cerebritis and acute hydrocephalus may sometimes be obscure, espe- cially in adults. We have seen that hydroce- phalus is often attended with inflammation and softening of the central parts of the brain. It may, however, be stated, in general, that in acute hydrocephalus there is seldom slow, partial, spas- modic paralysis of the extremities ; the sight and the speech are much more frequently affected. It is also characterized by high fever, general con- vulsions, irritability of the stomach, ending in a state of collapse and coma; symptoms much more resembling those of arachnitis than of partial cerebritis. When hemiplegia or other forms of paralysis have occurred during its progress, in- flammation and softening of the brain have gene- rally been found, in addition to the ordinary morbid appearances of hydrocephalus. It is of importance to attend to the circum- stance that, in children, diseases of the brain often come on very insidiously, and may have existed for some time previous to the appearance of any very decided symptom. The case of a child affected with fever, restlessness, headach, slight convulsions, irritability of stomach and vomiting, a foul tongue and disordered bowels, is looked upon as one of gastric remittent fever, or as the effect of dentition, whilst there is inflam- mation going on in the brain or in its membranes, which, however, is not suspected until delirium, strabismus, or convulsions, point out an advanced stage of cerebral disease. The condition of the brain, in the febrile and inflammatory affections of children, should always therefore be attentively watched. Some of the premonitory symptoms of cere- britis, such r.s pains in a limb, numbness, weak- ness, or stiffness, have been mistaken for rheumat- ism, and treated by local applications, while these symptoms were produced by disease of the brain. The absence of all local swelling, redness, or ten- derness on pressure, will assist in sufficiently dis- tinguishing the muscular pains in cerebritis. In the same manner vertigo, cephalalgia, irritability of temper, disturbed sleep, loss of appetite, and impaired digestion, indicating the* approach of cerebritis, have sometimes been treated as nervous or bilious headach, connected with dyspepsia; and the true character of the complaint has been overlooked, until the brain has sustained some material injury. The importance of diligently watching all those premonitory symptoms which indicate a threatened attack of cerebral disease, cannot be too strongly enforced. Epilepsy, chorea, nervous and hysterical con- j vulsions, and several other nervous affections, bear some resemblance in many of their symp- toms to those of cerebritis. We must refer, how- ever, to the history of these diseases, for a more particular account of their diagnosis. We shall only observe in general, that the greatest atten- tion is often required to discriminate cephalalgia, vertigo, confusion of sight, and other symptoms of affection of the brain, connected with vascular excitement, from purely nervous irritation. It must be remembered, in forming our diagnosis, that both causes sometimes re-act on each other. The absence of all tendency to permanent para- lytic affections in the purely nervous cases, will be a good general rule of distinction. Much use- ful information is moreover to be obtained by at- tending carefully to the predominant character of the temperament, and of the prevailing diathesis, whether sanguineous or nervous. The great irreg- BRAIN, (INFLAMMATION OF TH E ) —[CERE B RITIS.] 325 ularity and mutability of pure nervous symptoms form a striking contrast with the comparatively uniform and durable nature of those which ori- ginate, in disorder of the vascular system. We must not, however, be led to imagine that pallid, thin, and apparently nervous people, are exempt from inflammatory affections of the brain, or that others of a full habit and florid complexion are not subject to purely neuralgic complaints. There are some conditions of the system in which a distinction between the genuine and spu- rious symptoms of inflammation and compression of the brain is of great importance. A patient in a state of exhaustion after long illness, intense pain, copious bleeding, and other evacuations, is suddenly seized with violent headach, restlessness, hurried pulse, convulsions, coma, and apparently all the symptoms of acute cerebral inflammation. This is a common affection in children, and has often been mistaken for acute hydrocephalus. In other cases, after great anxiety and depression of spirits, a person is affected with delirium, incohe- rence, maniacal excitement, a hurried manner, great volubility, and hallucinations ; the pulse is hurried, rising suddenly to perhaps 160: these symptoms pass rapidly into fatal collapse and co- ma. No morbid alteration is found in the brain in these cases, except, perhaps, slight vascular injection. This affection has been mistaken for arachnitis, mania, hysteria, and its true nature overlooked, nntil the patient has rapidly sunk. The use of evacuations in such cases is sure to hasten death ; whilst under the timely adminis- tration of cordials, stimulants, and opiates, the symptoms are often speedily relieved. Towards the close of low fevers, when a decided amend- ment has taken place, a series of symptoms some- times occur, simulating a dangerous affection of the brain. The patient becomes restless, com- plains of headach, and does not sleep, and at length lapses into muttering delirium. These symptoms are, however, purely nervous and re- lieved by mild opiates and a moderate allowance of wine. Cerebritis may exist in combination with a variety of other diseases, such as hypertrophy of the heart, chronic inflammation of the lungs, the liver, stomach, and bowels ; with continued fever, measles, scarlatina, erysipelas, mania, &c. The diagnosis in such cases is not in general attended with much difficulty, although one disease some- times lessens the violence of the other. We have already directed attention to the important fact of severe cerebral inflammation completely conceal- ing for a time the existence of other diseases with which it may be combined. There are partial paralytic affections of the face, neck, and extremities, depending on inflam- mation and compression in the course of the nerves, or on diseases of the vessels, which may be referred by mistake to disease of the brain. We are indebted to Sir Charles Bell for a most interesting and satisfactory description of some of these affections. The absence of any cerebral symptoms capable of accounting for the paralysis will direct the attention of the practitioner to its real causes. The same may be said of the diag- nosis between cerebritis and paraplegia arising 2c from spinal disease, and the paralysis also occa- sioned by mineral or other poisons. Before concluding the subject of diagnosis, w« shall briefly allude to the interesting inquiries of some French pathologists, who have endeavoured to point out the parte of the brain affected in cere- britis, by the various modifications of the paralytic symptoms. We have seen that paralysis may affect one extremity, or both ; one entire side of the body, or the eyes, face, and tongue, either singly,or in a variety of combinations; that there are the same diversities in the state of the sensi- bility and intellectual faculties. How are these modifications to be accounted for > Several of the older writers had conjectured that, if the ner- vous filaments could be traced up to their remote origin in the brain, it would be found that each part of the body receives regularly its nerves from a determined part of the brain, so that any lesion of that part must necessarily affect the functions of the organ to which it sends nerves. The fol- lowing are the results of numerous pathological observations made on this subject, by MM. Fo- ville, Serres, Pinel Grandchamp, and Bouillaud. They are, of course, to be received with a good deal of reserve; but we still think them deserving of notice, if it were only to direct others in the path of inquiry. 1. The paralysis of the organs of speech de- pends on diseases of one or both anterior lobes of the brain. There are seventeen cases reported in the works of Lallemand, Rostan, and Bouillaud, with paralysis of the tongue, in which the ante-" rior lobes of the brain were found affected with various degrees of inflammation and softening; on the other hand, an examination of about fifty cases, in the same authors, without loss of speech or paralysis of the tongue, does not afford a single instance of inflammation or softening in the an- terior lobes. It should be noted that there may be loss of speech without paralysis of the tongue, from mere loss of memory ; and M. Bouillaud's observations lead him to think that the anterior lobes of the brain preside over the memory of words, as well as over the organs of speech. The above statement, if the facts on which it is found- , ed can be relied on, is certainly very remarkable, and deserving of further investigation. We remember an interesting case under the care of Dr. Cuming, of Armagh, in which there I was disease in the anterior part of the brain from ! a blow received on the forehead just above the ; nose : it was found necessary to remove a portion j of bone with the trephine; and after a variety of remarkable and untoward symptoms, the gentle- ! man perfectly recovered : one of the prominent ' symptoms was a loss of the memory of language. 2. The paralysis of the inferior extremities de- pends on disease of the middle lobes of the brain. and of the corpora striata. This conclusion is not supported by the same number of facts as the former. 3. The paralysis of the upper extremities de- pends on disease of the posterior lobes of the brain, and of the optic thalami. This is likewise stated as yet resting only on a small number of facts. The paralysis of one arm only has been observed in a good many cases, in connection 326 BRAIN, (INFLAMMATION OF T HE)--[CERE B RITIS.] with inflammation at the junction of the poste- rior and middle lobes. When several parte are paralyzed at the same time, the morbid altera- tions of the brain are supposed to be more exten- sive, or seated near the medulla oblongata. Pa- ralysis of the arm and leg on the same side, or hemiplegia, is supposed to follow the combined affection of the corpus striatum and thalamus, or else disease of the crus cerebri, from which these two bodies derive their origin. The last speculation on this subject which we shall refer to, is one relating to the respective uses of the cortical and medullary substances of the brain. We have seen that the cortical sub- stance has been found, in a great many lunatics, highly injected, and often inflamed, whilst the medullary substance remained healthy. M. Fo- ville and Pinel Grandchamp have conjectured from this and some other circumstances, that the cortical substance was the seat of intelligence, whilst the medullary was intended to preside over motion. The principal other grounds of this hy- pothesis are, the apparent decrease of the cortical substance, which has been found reduced to a very thin layer, in cases of imbecility ; the small size of the convolutions and small quantity of cortical substance observed in the brains of idiots, compared with those of intelligent beings. In the article Encephale, of the volume of the Dictionnaire de Medecine et de Chirurgie Pra- tique, just published, M. Foville, whose recent discoveries on some points of the minute anato- my of the brain have deservedly attracted much attention, enters at considerable length into the examination of the preceding considerations. He has adduced a number of striking facts and argu- ments in their support, and lays down the follow- ing general propositions : 1. The. joint lesion of the corpus striatum and thalamus of one side gives rise to the same paralytic symptoms as the lesion of the whole fibrous substance of the corresponding hemisphere, of which they are in some manner the centres or nuclei. 2. The lesion of the crus cerebri is followed by the same paralytic symptoms as that of the corpus striatum and thalamus, which are them- selves in a great measure formed by the expan- sion of the fibres of the crus. 3. A lesion of the medulla oblongata pro- duces all the symptoms which arise from the joint affection of the crura cerebri and cerebelli; and if we ascend still higher in the brain, from that also of the corpora striata, thalami, and hemispheres. i. If we direct our attention to the portion of : fatal symptoms tremely delicate structure, however, of the brain, its situation in a bony unyielding case, without room for expansion, or any opening for the exit of effused fluids, and the great importance of the integrity of its functions to the preservation of life, are circumstances which must always connect a considerable degree of danger with its inflam- matory affections. It may be said in general, that so long as the inflammation is only in the first stage, and the texture of the brain not broken down by the infil- tration of blood, pus, or serum, resolution is still possible. The following circumstances may lead us to hope for this favourable termination: the paralysis being only partial; the muscles firm, not flaccid, and retaining some degree of motion; the sensibility being little impaired ; after an at- tack of coma, a gradual return to consciousness, without affection of the intellect; sound sleep; the tongue cleaning, and motion progressively re- turning in the paralyzed parts. It must not lie forgotten, however, that there are frequently exacer- bations and remissions in the symptoms; intervals of apparent recovery and a great tendency to re- lapse. It has been already stated that a delusive amendment often attends the passage of the in- flammation from the first stage into that of soften- ing or suppuration. Such an amendment, there- fore, at a late period, is more to be suspected than in any earlier stage of the disease. The continu- ance of headach, uneasy sleep, shiverings, and languor are unfavourable symptoms, whatever may have been the amelioration in other respects. Headach and delirium are less unfavourable than stupor and coma. When profound coma is suc- ceeded by headach and delirium, this is rather a favourable occurrence, as it indicates a return of the previously paralysed action of the brain; when, on the contrary, they are followed by coma, it is a bad omen. The danger is of course in proportion to the extent of the paralysis, and greater in complete hemiplegia than when the paralysis is confined to one limb. When the paralysis extends, to the side of the body which was at first free, the danger is imminent, since both hemispheres are then affected ; and when both sides are simultaneously paralysed, a speedily fatal termination may be predicted. Embarrassed breathing is always a bad symptom. When the inflammation has reached the second stage, and the diseased portion of brain has be- come softened and infiltrated with pus, the danger is great and the recovery very doubtful. Paralysis of the bladder and retention of urine are generally the nervous system below this great centre of the nervous action of the brain, we shall find the cerebral influence continue unimpaired in all parts superior to any lesion of the spinal marrow, whilst it is completely intercepted in parts infe- rior to that lesion. Prognosis.— Cerebritis is a disease always attended with considerable danger. Wfren once fully developed, it has hitherto been generally considered as incurable; but since we have been enabled, by a better knowledge of its true nature, t> apply with promptitude more appropriate reme- dies, the treatment is often successful, even under the most unpromising circumstances. The ex- The chronic form of cerebritis, accompanied by very slow and creeping palsy, is always an un- promising disease. The circumstance of the symptoms at first beim; slight, and confined to an apparently trifling numbness or weakness in a few muscles, must not throw the practitioner off his guard. This form of disease is almost always attended with a considerable degree of failure of the powers of the constitution; and sooner or later, in the majority of cases, comes to an unfa- vourable termination. The more acute cases af- ford a better prospect of recovery, there being sufficient strength to admit of the use of active remedies. BRAIN, (INFLAMMATION OF THE ) —[CERE BRITIS.] 327 The coma and paralysis following a sudden I attack of sanguineous apoplexy are attended with less danger than the coma and complete paralysis of the latter stage of cerebritis ; for there are nu- merous instances of the resorption of a clot of blood, whilst those of the resorption of pus and healing of an abscess are extremely rare. The inflammation of the brain consecutive to san- guineous apoplexy is always dangerous, and greatly lessens the chances of recovery. Cere- britis following concussion is generally severe, and attended with greater danger than that con- sequent upon an injury of the head with opening in the skull. The duration of cerebritis varies according to its form. Acute cerebritis generally runs a rapid course; it may prove fatal the first, second, or third day, and seldom lasts more than from ten to twelve days. Chronic cerebritis is very variable in its duration, being often attended with inter- missions and relapses; the disease may thus be prolonged for several months, and some cases have been described as lasting even several years; but it is more than probable that when symptoms resembling those of cerebritis continue beyond five or six months, they do not arise from genuine cerebral inflammation, but are to be attributed either to an organic tumour, or to some neuralgic affection simulating chronic cerebritis. In a col- lection of thirty-four cases, nine died in the course of the first week, six in the second, six in the third, two in the fourth, and eight in the course of from two to six months. With respect to age, it appears that old age and childhood are the two periods of life the most exposed to cerebral inflammation. The examina- tion of a large number of cases shows that more than two-thirds were persons above forty-five, and a majority of these between forty-five and seventy. It is a disease, however, which may affect all ages. The frequency of falls and blows on the head in children, the irritation of dentition, the pressure of the head during parturition, predispose them to cerebritis, although there is perhaps a greater tendency at that period of life to mem- branous inflammation. Traces of cerebritis have been found in still-born children. Men are more subject to cerebritis than women, in the proportion of about two-thirds, owing probably to their being more exposed to the influence of exciting causes. The disease, also, is more common in hot than cold climates, and in summer than winter. Causes. — The causes are predisposing and exciting. The only difference, however, between these often consists in their degree of activity; since a predisposing cause may become exciting if its activity be sufficiently increased. Every circumstance capable of causing congestion, or of disturbing the balance between the arterial and venous circulation in the brain, becomes a predis- posing cause. These circumstances are a plethoric habit, particularly in individuals who have short necks and are subject to habitual constipation, the diathesis justly termed apoplectic. Persons, how- ever, of a thin habit and slender make, with long neck and pallid countenance, and especially if such individuals are intelligent, are also under certain circumstances predisposed to cerebral af- fections, particularly when labouring under disease of the heart. An hereditary tendency to fulness in the head and diseases of the brain may be recWoned among the predisposing causes. Hyper- trophy of the heart, particularly of the left ven- tricle, is a very common predisposing and some- times exciting cause. The celebrated Malpighi died of an inflammatory affection of the brain, attributed to hypertrophy of the heart, from which he had long suffered. Disease of the heart acts either by impeding the regular return of the blood from the head, or causing the blood to be propelled with excessive impetus towards the brain ; the latter takes place more particularly when the hy- pertrophy is produced by obstruction in the aorta beyond the origin of the carotid arteries. Inflam- mation of the lungs, phthisis, and asthma act in the same manner in producing cerebritis, though these diseases are less powerful exciting causes than those of the heart. There is a great predis- position in phthisis to sudden attacks of inflam- mation of the brain or its membranes ; the patient is all at once seized with intense headach and violent delirium, ending sometimes in confirmed mania, and it is very remarkable that the pulmonic symptoms, howsoever severe, have often in such cases suddenly disappeared, and have not returned until the attack in the head had subsided, the two affections thus alternating the one with the other. It cannot be said in every case that the cough and other pectoral symptoms are merely obscured, for we have seen cases of perfect recovery from an advanced stage of phthisis, by the supervention of an attack of mania. These are striking exam- ples of the actual translation of disease. Dr. Abercrombie very justly observes that there may be in scrofulous constitutions a tendency to scro- fulous inflammation of the brain, and that the disease of the lungs is not properly to be always considered as the cause of the head affection ; that in the same manner disease in the brain may appear in connexion with the disease of any other organ, and that diseased liver has often been thus improperly stated to be the cause of hydro- cephalus. The mutual influence of the functions of the brain and digestive organs on each other is so obvious as not to require any explanation; and thus the headach, drowsiness, and other signs of cerebral congestion, which follow over-distension of the stomach, or the abuse of spirituous liquors, are easily accounted for. Habitual drunkenness is perhaps one of the most powerful causes of cerebritis or arachnitis. The striking similarity between the symptoms of the last stage of in- toxication and those of apoplectic coma has been frequently noticed. The subacute inflam- mation of the mucous membrane of the stomach and bowels, the gastro-enterite of Broussais, is often accompanied by great cerebral irritation. This complaint, in young children from two to four years old, frequently terminates in coma. A vitiated state of the secretions of the alimentary canal is a very active and frequent cause of cere- bral irritation; it accompanies that fretfulness and irritability of temper which so commonly pre- cede attacks of inflammation in the brain . the convulsions produced by intestinal worms are also the effect of sympathetic irritation. There is a disease of the urinary organs, known 328 BRAIN, (INFLAMMATION OF THE) —[CEREBRITIS.] as ischuria renalis, of rather uncommon occur- rence, which predisposes sometimes to dangerous affections of the brain. Sir Henry Halford has published an interesting paper on this subject. (Transactions of the College of Physicians, vol. vi. p. 398.) In many of the cases, after the pa- tient has suffered for two or three days from dull pain and sense of weight in the ilac regions, these symptoms are succeeded by great anxiety, nausea, vomiting, hiccup, cramps, slow pulse, de- lirium ; and he gradually fills into a state of lethargy and coma. The ventricles of the brain are found on dissection distended with serum. The suppression of urine is sometimes not complete ; if there be perspiration, it may have a urinous smell. Suppression of urine is sometimes not attended with any marked inconvenience. Dr. Parr, in his dictionary, mentions the case of a person who had suppression of urine for six weeks and yet recovered. Dr. Abercrombie gives a case in which the suppression was occasioned by obstruction of both ureters; the patient died on the thirteenth day, of a cerebral affection. Ischuria renalis has in some instances been supposed to originate in a disease of the brain, causing paralysis of the kidneys. The persons most subject to this affection are fat corpulent men, between fifty and sixty years of age, of a gouty habit, and naturally predisposed to cerebral congestion, though it is sometimes also met with in children. We have already said that inflammation of the brain may occur in the course of a variety of febrile diseases, such as continued fever, scarlatina, measles, &c. It has often been observed as one of the sequela? of scarlatina; and when accom- panied with anasarca, its inflammatory character has been entirely overlooked, and attributed to mere serous effusion in the brain. There is a great tendency to cerebral congestion in the con- tinued fevers of this country ; thus of eight hun- dred and sixty-four cases treated in a large fever hospital, six hundred and two presented head symptoms. Suppuration of the brain may some- times occur in the course of fever, but it is not very common; of fifty cases of fever with well- marked cerebral symptoms, pus and blood oc- curred in only three. Subacute inflammation of the membranes is of much more frequent occur- rence. The injury, however, sustained by this organ during an attack of fever with violent head symptoms, often gives a predisposition to future cerebral inflammation. Among the predisposing causes are to be ranged suppressed evacuations. That of the catamenia, especially in young women, is often followed by dangerous affections of the brain. A similar re- sult may attend the suppression of artificial dis- charges and of cutaneous eruptions, the healing of chronic ulcers, erysipelas, gouty or rheumatic affections of the joints, &c. Over-exertion of mind, depressing passions, such as grief, fear, &c. great bodily fatigue, long-continued nervous head- achs, and all neuralgic affections of the brain, epilepsy, and mania, operate as predisposing and sometimes exciting causes. The brain cannot long suffer from nervous irritation without a re-action taking place in its vascular system. External injuries are among the most direct ex- citing causes; and this is much more frequently the case than is imagined, particularly in children. A considerable interval, sometimes two or three weeks, may intervene between the injury and the appearance of alarming symptoms; and a very trifling fall or blow, which is often the cause of serious disease, may have been altogether over- looked or forgotten. Exposure to the intense heat of the sun is a powerful exciting cause. It may bring on either arachnitis, cerebritis, apoplexy, or mania. The same results may follow a sudden transition from heat to cold. Long exposure to intense cold acts also in a remarkable manner on the brain, bring- ing on inflammation, and sometimes the most vio- lent maniacal delirium : there were many remark- able examples of this during Napoleon's cam- paign in Russia. Inflammation and suppuration of the internal ear has a great tendency to extend to the brain, and it is in this manner it often proves fatal. Te- dious and painful dentition is a great source of cerebral irritation; intense and long-continued pain from any cause often brings on delirium and coma. The ligature of large branches of nerves in the neighbourhood of the head has had this effect; of which the following case, related by Lallemand, is a remarkable instance. The sub- clavian artery was lied above the clavicle for an aneurism in the axilla on the right side; several branches of the brachial plexus, supplied by the third cervical, were included in the ligature; in- tense pain was immediately felt in the neck; this went on increasing, notwithstanding the most active treatment; coma, convulsions, and a strong retraction of the head appeared the seventh day; j the patient died on the eighth. The posterior ! portion of the left hemisphere of the brain pre- sented a large undefined abscess, containing soft- ened diffluent brain, and in the centre greenish pus; the sides of the abscess were deeply injected; the arachnoid was healthy. Such a case is inter- esting both to the pathologist and physiologist. The internal use of certain narcotic and irri- tating poisons may become a cause of cerebral in- flammation. This is the special property of nux vomica; and we have seen its unguarded admin- istration in hemiplegia bring on a fresh attack of inflammation of the brain. The inhalation of putrid effluvia and contagious miasmata, particu- larly in very hot climates, and when the system is in a state of depression, has been quickly followed by cerebral inflammation. We had experience of this ourselves some years ago, while attending a fever hospital. After inhaling a horrid foetor which emanated from a patient in an advanced stage of typhus gravior, we were instantly seized with sickness and headach, as if struck by a blow, and, in less than forty-eight hours after, a dan- gerous attack of typhus fever supervened, attended by strong cerebral symptoms. The action of these numerous causes is very variable; sometimes sud- den and rapid, at others slow and imperceptible. Treatment.—The inflammatory nature of the more acute forms of cerebritis and arachnitis is so obvious, that their treatment has always been con- ducted on correct principles. Until very lately, however, the inflammatory character of partial and chronic cerebritis was either entirely over- BRAIN, (INFLAMMATION OF THE) —[CEREBRITIS.] 329 looked, or so imperfectly understood, that though I the feet or legs, by opening a vein, or applying active treatment was sometimes adopted at the ' leeches and letting them bleed in a foot-bath; or beginning of the disease, it was soon laid aside, i the application of leeches to the anus, whenever and remedies of an opposite description substi- practicable. We have found this the surest mc- tuted. These affections were in fact generally set i thod of affording permanent relief; and by repeat- down as nervous; mistaken for rheumatism, neu- I ing it at certain intervals, the tendency to cerebral ralgia, nervous dyspepsia, and debility, or nervous I congestion may be completely overcome. We palsy, and treated by tonics, electricity, and stimu- | have pursued this plan in lunatics with the very lants; the fatal termination of the disease being | best results. It was a practice of the ancients, thus accelerated. Cerebritis and arachnitis are so formidable, that their prevention is of no less, if not of greater importance, than their treatment It is extremely important to have recourse to active measures on the very first appearance of any of the premoni- tory symptoms, however trifling : as we may thus succeed in effectually removing that state of con- gestion and irritation of the brain, which is the precursor of inflammation. The means of accom- plishing this are, the careful and timely removal of all the exciting causes; of every source of irri- tation, both bodily and mental; regulation of the diet; avoiding all excesses ; relaxation from study, change of air, general and local bloodletting, counter-irritation, with occasional purgatives. Great vigilance is particularly required in the ce- rebral affections of infants and children, who fre- quently suffer without complaining. A predispo- sition to affection of the brain may often be sus- pected by some slight cast or rolling of the eyes ; by dilatation of the pupils; or occasional start- ings, and attacks of spasmodic croupy breathing during sleep: there may be every other appear- ance of perfect health with these symptoms, which are. often only evanescent; but they will not es- cape the attention of the experienced observer, and will be sufficient to put him on his guard. When it is necessary to relieve the brain from habitual congestion by occasional topical bleeding, the method of taking blood from parts as remote from the disease as possible, seems to us prefera- ble to that of abstracting blood from the head itself. When the vessels of a part are partially emptied of their blood, if they have been much weakened by long-continued over-distension or previous disease, so as to have lost their elasticity, there will be an immediate flow of fresh blood to the part; this will take place on mere hydrostatic principles. We have thus seen in an eye long exposed to injection and low inflammation, the redness and suffusion much greater the day after an application of leeches than it was before ; and we have likewise known headach considerably increased in plethoric and bloated people, after leeches had been applied to the temples. On the other hand, no fact is better established than that the loss of an exceedingly small quantity of blood from certain parts of the body is sufficient to re- lieve distressing symptoms of congestion and oppression in others most remote from them; as, f >r instance, a very slight discharge of blood (one or two ounces) from the hemorrhoidal veins being sufficient instantly to remove vertigo, flushing, headach, or oppressed breathing : the same is the case in a still more striking manner with the cata- menia, although some account must be taken of the influence of uterine irritation over the system. We prefer, therefore, in cases of habitual conges- tion in the brain, taking blood occasionally from Vol. I. —42 2c* which has, in our opinion, been too much laid aside. When, however, there is active inflamma- tion in a part, as it is most material to unload the vessels freely and quickly, the blood had better, in such a case, be drawn from the immediate neigh- bourhood of the organ affected. The insertion of an issue is often advisable, as a preventive, in people of a plethoric habit. The head should be kept cool by the frequent use of cold ablutions; the hair cut short; the head and shoulders raised at night; tight bandages round the neck must be avoided ; the daily use of the cold shower-bath is often very beneficial; but a re-action takes place in the head unless it be used with the feet immersed in hot water. The feet, legs, and lower parts of the body ought to be carefully kept warm and dry. In the treatment of cerebritis, when fully deve- loped, attention must be paid to its two periods of excitement and collapse. The remedies chiefly to be relied upon are, bloodletting general and topical, purgatives, cold applications to the head, and counter-irritation. In the more acute cases the patient must be freely bled from a large orifice to the amount of from twenty to forty ounces: one copious bleed- ing has more effect in bringing about the speedy resolution of the inflammation than several small bleedings. If the symptoms continue unabated, the bleeding must, however, be repeated several times, at intervals of a few hours ; and this prac- tice must be carried, during the first period of the disease, to the utmost limit of the patient's strength. It often happens that very little im- pression is made on the disease by the first bleed- ing, and no amendment takes place until after the second. The symptoms often abate after bleed- ing ; hut a fresh exacerbation may take place in the course of a few hours. Topical bleeding, by cupping or leeches, is, under such circumstances, highly beneficial. The head must be shaved, and pounded ice mixed with cold water and vinegar may be ap- plied to the scalp. A very effectual method of applying cold is by making the patient hold his head over a basin, and pouring a stream of cold water on it from a certain height: this often removes the heat and flushing, and calms the ex- citement : it should be repeated as often as the heat and flushing return. The application of cold to the body is always followed by a re-action, and the temporary relief refrigerants afford will be succeeded by an increase of the inflammatory symptoms, and their use become decidedly inju- rious unless their depressing action be kept up by a steady and repeated application. Some practi- tioners have, on this account, given the preference to the use of a mixture of alcohol or ether with liquor ammonia? acetatis and water, applied not quite cold, in order to produce rapid evaporation. 830 BRAIN, (INFLAMMATION o An excellent practice is that of keeping the patient's feet and legs immersed in hot water dur- ing the application of cold to the head. The remedies next to bleeding and cold, and often not less efficacious, are active purgatives, which must be administered at short intervals until copious evacuations be procured. Free purging sometimes makes a greater impression on the dis- ease than even bleeding. In some cases no marked amendment has taken place until the bowels have been freely moved : they are some- times exceedingly torpid, for reasons which have been already assigned, and large doses of cathartics may be required. Combinations of calomel, jalap, scammony, and cathartic extract, followed by an infusion of senna with salts, are the purgatives on which the most reliance can be placed. Croton oil is also in these cases a valuable remedy, from the facility of its administration and certainty of its effects. Mercury may be given freely as a purgative, but no particular advantage has appear- ed to follow its use with a view to affect the con- stitution ; it is, indeed, found very difficult in acute diseases to produce ptyalism. We have sometimes found tartar emetic of great service when there was no irritability of stomach to prevent its being tolerated; the power of tartar emetic in controlling the action of the heart, and subduing the inflammatory diathesis, is now fully established : a solution in the proportion of one grain to the ounce, and two table-spoonsful given every two, three, or four hours, suspending it should vomiting occur, has often been attended with great benefit. The remedy is in general well tolerated, owing to the torpor of the stomach: violent vomiting should, however, be prevented, as it would obviously be extremely injurious. In the second stage of acute cerebritis, that of collapse and coma, general bloodletting is to be used more sparingly; decided advantage, however. has resulted from a moderate bleeding even at a late period. In this stage, topical bleeding is more generally indicated. There are periods of exacerbation in the symptoms which should be watched and overcome by these means; which may be persevered in as long as there is any hard- ness and resistance in the pulse. We have seen a patient instantly recover from a state of profound coma by the abstraction of a very small quantity of blood with the cupping-glass. When bleeding is no longer advisable, moderate purging may still be of use. In this stage, we may have recourse to counter-irritation with advantage : blisters may be applied between the shoulders, to the occiput, or to the neck or legs. There is an objection to their being applied to the whole head, that it pre- vents the subsequent application of cold. We have, however, in desperate cases, seen a decided amendment follow the application of a large cap blister. Particular attention should be paid to the abdominal region, and especially that of the blad- der, which ought to be examined morning and evening, in order to detect retention of urine; and we must take care not to be led into error by an incontinence of urine from the over-distension of the bladder: this must be obviated by drawing off the urine with the catheter twice a day. In the more chronic forms of cerebritis, unat- tended with fever or much general excitement, the OF THE) —[CEREBRITIS.] same activity of treatment is of course not admis- sible. We must still, however, pursue the anti- phlogistic plan, modifying it according to the urgency of the symptoms. During the period of irritation, with cephalalgia, vertigo, or rigid spasm of the extremities, moderate bleeding, general and topical, purgatives and counter-irritation, are the only remedies from which any advantage is to be expected : they must be repeated at longer or shorter intervals, according as the strength of the patient and the continuance of the symptoms may seem to indicate. A great deal is to be accom- plished in all chronic inflammations by persevering in a moderate course of antiphlogistic treatment. We must watch carefully any signs of amendment, remembering that there is a great tendency to re- lapse, and that the natural course of the complaint is characterised by irregular remissions and exa- cerbations. When the period of irritation is over, and is followed by a remission of all signs of excitement, by a complete paralysis of the muscles, and by the other evident signs belonging to the period of softening and suppuration, the strength of the patient must no longer be reduced by active treat- ment. In all inflammatory diseases, when the stage of excitement and disorganization is over, a process of reparation commences, which requires for its completion a certain degree of power in the constitution. If at this period we persevere in lowering the general strength, we deprive the constitution of its natural resources, and interfere with its healing operations. It becomes, therefore, an object of considerable importance to watch the moment when the tide of excitement is on the turn, and when the powers of the constitution are verging to a state of collapse, in order that we may abstain from an injurious interference, hus- band the patient's strength, and even support it if required. This precaution is particularly neces- sary in old people and young children. We think it necessary to lay some stress on this rule of practice, as there is perhaps a tendency in the present day to overlook it; and we have seen considerable harm from carrying the antiphlogistic treatment beyond its safe limitation. We have already alluded to the pseudo-symptoms of cere- bral congestion and inflammation which are some- times the consequence, especially in children, of extreme exhaustion, and require the use of cordials. After convalescence has been established, the patient will still require to be closely watched for some time, before his recovery can be considered fully confirmed : he must be kept perfectly quiet, free from every species of excitement, and the regimen duly regulated. When the brain has once suffered from inflammation, it is slow in re- covering its tone, and the most trifling cause, such as a slight mental exertion or emotion, a full meal, &c, has been, in many cases, sufficient to occa- sion a relapse. When cerebritis has occurred after suppressed evacuations or the metastasis of other diseases, we should endeavour to procure their return. If menstruation be suppressed, leeches should be applied to the pubis or inguinal regions, and the frequent use of hot pediluvia with flour of mustard recommended. If cutaneous eruptions or rheu- matic gouty pains in the joints previously existed, BRONCHIAL GLANDS-BRONCHITIS. 331 blisters or rubefacients are to be applied to the parts originally affected. M. Blaud has published in the Bibliotheque Medicale, vol. lxii. several cases in which he says that he speedily overcame the symptoms of cere- britis by the mere compression of both carotids for several seconds; stopping thus the flow of blood to the head. Laennec considered this an unsafe proceeding, and not easy to perform without the risk of suffocation. This plan has often been proposed as a means of checking in- flammation, and also of preventing the accession of the paroxysm of ague. We have, however, never seen it tried, and should think its general application scarcely practicable. The following summary gives a connected view of the various morbid conditions of the brain, which are the effects of congestion and inflamma- tion, together with their symptoms. 1. Cerebral congestion, over-distension of ves- sels :—vertigo, tinnitus aurium, confusion of sight, cephalalgia ; if the pressure on the vessels be car- ried to a sufficient extent to intercept the circula- tion,—simple apoplexy ; seldom fatal; recovery rapid. 2. If the cerebral congestion be permanent, or returns frequently; drowsiness, oppressed intel- lect ; the vessels become weakened, and on a sud- den increase of congestion are ruptured; extrava- sation of blood,—sanguineous apoplexy; destruc- tion of cerebral substance and compression ; loss of consciousness, permanent or temporary; sudden and complete paralysis, without spasmodic affec- tion of the muscles. 3. General congestion, followed by inflamma- tion of a considerable portion of the brain ; deep injection; partial sanguineous infiltration; dotted and ecchymosed striated appearance of the cerebral substance;—•-general cerebritis, (combined usually with arachnitis). Period of high excitement of all the cerebral functions, with general convul- sions, followed by a period of collapse and coma. 4. Partial congestion and inflammation of the brain: 1st period, the same deep injection and sanguineous infiltration, more circumscribed;— partial cerebritis. Partial symptoms of irritation in the organs of motion and sense; weakness, pain, numbness, spasmodic paralysis, confined to one side or a few regions of the body: 2d period, infiltration of pus in the cerebral substance; sof- tening, abscess; complete paralysis ; relaxation and flaccidity of the muscles; loss of feeling; abolition of some of the external senses or intel- lectual faculties; death, either gradual or sudden, by the extension of the inflammation, or by pres- sure. 5. After sanguineous apoplexy and sudden and complete paralysis, inflammation of the cerebral substance surrounding the coagulum ; consecutive cerebritis ; the paralysed limbs affected with pains, convulsive motions, spasmodic rigidity. 6. Slow and gradual congestion, with very slight irritation ; long-continued state of low in- flammation, ending sometimes in softening, some- times in induration, or else in an infiltration of serous fluids and white softening;—various forms of c/ironic cerebritis,- sense and motion very gra- dually weakened and impaired, without pains or spasmodic rigidity in the muscles. Adair Crawford. [BRIGHT, DISEASE OF. (See Dropst.) BRONCHIAL GLANDS, DISEASE OF THE. The bronchial glands, or ganglions, seated around the bronchia, where they dip into the tissue of the lung, are not uncommonly found larger than usual, without there being any evidence of their morbid condition during life; and hence it has been concluded that, when hypertrophied, or otherwise diseased, they seldom produce any striking symptoms. (Stokes, on Diseases of the Chest, Amer. edit p. 266, Philad. 1844.) Thus, in a case recorded by M. Andral, (CUnique Medi- cale, torn i.) where an enormous mass of melano- sis compressed the right bronchium, so as to di- minish its diameter by one half, there was no stridulous breathing, the signs being a feeble re- spiration in one lung, with intense puerility in the other. He states, however, that tumours of the bronchial glands frequently cause bronchial and tracheal compression. It need scarcely be said, that if they are so large as to compress the bronchial tubes, they must interfere with breath- ing; still, the compression may arise so gradually as to account for the very slight effect they in- I duced on the breathing in certain recorded cases. In children, they are frequently enlarged by the deposition of tuberculous matter, and may give occasion to dyspnoea, and to evidences of ob- structed circulation. Dr. Stokes (op. cit.) affirms that he has never met with an instance of stridu- lous breathing, or even bronchial compression, produced by their diseased condition; but Dr. Golding Bird has recorded cases in which such compression was witnessed. (See the writer's Practice of Medicine, 2d edit. p. 383, Philad. 1844.) Tumours of the bronchial glands would appear generally to grow forwards, and Dr. C. J. B. Wil- liams (Lectures on the Physiology and Diseases of the Chest, &c. Amer. edit. p. 252, Philad. 1839) states, that he has seen them pushing out the sternum or the ribs on one side, and causing dul- ness of those parts, and symptoms of displacement of the lungs farther down. When the glands are greatly augmented in children of scrofulous habits, there are no signs that can lead to more than a suspicion that the morbid state exists. The scrofulous diathesis may be accompanied with tuberculosis of the lungs; and, if evidences of compression of the bronchia exist, there may be no signs that can enable us to pronounce positively, that such compression is owing to enlargement of the bronchial glands. These scrofulous enlargements sometimes soften, and are evacuated, by ulceration, into the bronchia. The bronchial glands are also, sometimes, affected by encephalosis; and it has been suspected by Dr. Williams (op. cit.) that encephaloid disease of the lungs generally originates in this way, and spreads afterwards along the vessels into the pul- monary tissues. Should scrofulosis of the bronchial glands be suspected, the treatment must be such as is proper for the scrofulous cachexy in general. Robley Dunglison.] BRONCHI, DILATATION OF. (See Baoy- CHIT1S, CHRONIC.) BRONCHITIS. This term is applied to in- flammation of the mucous lining of the bronchi 332 BRONCHITIS —[ACUTE.] or air-passages of the lnngs. There are few dis- orders of more common occurrence ; and few, perhaps none, so varied in importance. In its slighter forms it is scarcely deemed an interruption to health ; but when severe, it becomes a danger- ous and fatal disease. The pathology explains this diversity, and refers the danger, which attends bad cases, to interruption of the due performance of the function of respiration. It does not seem correct, therefore, to describe these different de- grees under the different names, catarrh, bronchi- tis, peripneumonia notha, &c. as some authors have done. The term catarrh implies only the flux or secretion which accompanies the inflam- mation. We shall therefore include under the present head all affections of the bronchial mem- brane, which exhibit the characters of inflamma- tion, and reserve the term catarrh for those changes in the secretion of the same membrane that do not appear to originate in inflammation. Bronchitis presents itself under two forms, the acute and the chronic; the one differing from the other in the greater intensity of the inflammation, and in the more rapid progress of the disease. We shall therefore cons'der each form separately, as this method will enable us to point out the cir- cumstances which characterize each variety. I. Acute Bronchitis.—The commoner cases of acute bronchitis generally succeed to coryza, or inflammatory affection of the mucous membrane lining the nose and its contiguous cavities, the frontal sinuses. Sometimes the inflammation first attacks the tonsils and fauces, from thence is tranferred to the lining of the larynx, and gradu- ally extends downwards to the trachea and bron- chi. In other instances the inflammation begins in the bronchi themselves; and this mostly occurs in those whose lungs are susceptible. The first symptom which characterizes bron- chitis is a feeling of roughness in the trachea, which occasions frequent attempts to clear the throat, and is much increase;d by exertions of the voice, or of the organs of respiration. It soon amounts to such a degree of titillation as to excite cough, which is at first hard and dry. At this time there is generally more or less hoarseness, with a tight feeling across the chest, which often amounts to pain, especially on coughing, and occasions considerable uneasiness in breathing. Some signs of fever are usually felt at this period, such as lassitude, cold shiverings, pain in the limbs, and some acceleration of the pulse. A feeling of chilliness is hardly ever entirely absent, even in the slightest cases. The cough, which at first seems to be caused by an increased sensibility of the inflamed membrane, is very soon accompa- nied with expectoration of a thin fluid, having a saline taste. This secretion rather increases than otherwise the frequency of the cough; and, like the fluid of coryza, when thin it seems to possess a peculiar irritating quality ; for, although the fits of coughing are not so prolonged as they after- wards become, they are more frequent and more irresistible than at any stage of the disease. It is during the continuance of this form of secretion, likewise, that in the common cases of bronchitis, the dyspnoea and pain in the chest first appear ; and as the expectoration becomes thicker and more abundant, these are proportionately relieved. It is this change in the character of the cough and expectoration, that in common cases proves the signal for a general amelioration of the symptoms. The constriction of the chest is diminished or re- moved; the pulse loses its frequency; the skin, which was hot, becomes cooled by free perspira- tion ; the urine, which was scanty and high- coloured, becomes more copious, and deposits an abundant sediment; and the degree and rate of the decline of all the troublesome symptoms very generally correspond with the change of the ex- pectoration. This seems now to have lost its acrid ' irritating quality, and has less of the saline taste | which at first characterized it. In its appearance it changes from a glairy colourless liquid to a | pearly tenacious phlegm, increasing in consis- i tence and opacity as it diminishes in quantity, 1 until at length each fit of coughing easily brings up a pellet of opaque white, or greenish white | mucus, to which the soot and smoke of the air in | large towns often give a grey tinge. This change, or ripening of the expectoration, is first observed ! in the mornings only, and gradually extends, as the disease declines, throughout the day and night. I Towards its termination, the cough and expecto- ration are chiefly observed in the morning and evening. Such is the ordinary course of the slighter cases I of acute bronchitis, for which the nature of their usual cause has obtained the name of " a common | cold." But the same disease, differing from | these only in the extent of membrane affected, . presents a much more formidable character. In such severe cases, rigors and symptoms of general fever usually attend at the onset of the disease. The patient suffers from headach, particularly over the eyes, sickness and loss of appetite, lassi- tude and great prostration "of strength, with occa- sional pains in the limbs. The tonghe is foul, and the urine scanty and high-coloured. The dys- pnoea is often urgent from the beginning, particu- ! larly in the night; and this symptom, as well aa I the tightness and pain in the chest, is much aggra- vated by the fits of coughing. The pain in the I chest is most frequently referred to the sternum, I and is more obtuse than the pain of pleurisy ; it is j often accompanied with a sense of weight to which I the dyspnoea is ascribed. The pulse is hard and | quick, but presents considerable variety as to the degree of frequency and fulness. The matter expectorated is usually scanty at first, and after- wards becomes copious ; it is glairy, frothy, some- times streaked with blood, and its evacuation affords but little relief to the cough or breathing: it has been compared to the white of egg in differ- ent degrees of dilution : it is generally most frothy j when moderately viscid and in great abundance: its quantity increases, and there is a general aggra- | vation of all the symptoms in the evening. It is at this time that the fever increases, the dyspnoei ! is most oppressive, and the cough most distress- ing. j Between the fourth and the eighth days the disease declines in favourable cases ; the dyspnoea i is diminished, and is confined chiefly to the even- ing, when there is almost always a tendency to exacerbation. The expectoration now becomes \ pearly and less abundant, and affords relief to the | dyspnoea. The symptoms of fever subside, and BRONCHITIS — [ACUTE.] 333 the disease either entirely disappears or passes into the chronic form. In certain cases, however, if the therapeutic means have not been seasonably resorted to, or have been insufficient to subdue the acute symptoms of the disease within a few days, a state of collapse very rapidly takes place; the pulse becomes very weak, frequent, and often irregular; the countenance pallid and expressive of great anxiety, and often covered with a cold sweat; the strength is wasted by efforts to relieve the lungs of the accumulating mucus; but the cough becomes less and less effectual to remove it whilst the wheezing and audible rattle in the large air-tubes increase. Lividity, delirium, and other symptoms of the circulation of black blood in the system, frequently succeed, and the patient dies suffocated. A remarkable feature in the character of the worst form of bronchitis is, the rapidity with which the collapse and symptoms of extreme prostration and debility succeed to high fever and well-marked local excitement; and this circumstance indicates the serious nature of the attack on the vital functions. The whole course of these fatal cases is sometimes wonderfully rapid; death ensuing within two days from the com- mencement of the attack. They are commonly confounded with pneumonic inflammation, and are scarcely to be distinguished from it during life but by the physical signs. The severest form of bronchitis is, however, more formidable and rapid in its course than pneumonia itself. In the extremes of age, and in persons of Weakly and phlegmatic habit, acute bronchitis frequently presents a form so different from what has been just described, that it is necessary to advert a little to these varieties. In young chil- dren a very fatal kind of bronchitis not unfre- quently comes on in a most insidious manner. It may present at first the aspect of a common catarrh with coryza, without pain, much fever, or derangement of the general health. Attentive observation, however, discovers a frequency and wheezing in the breathing, which is uncommon, particularly before and after the fits of coughing ; and the pallidity of the countenance and heavy state of the child's spirits indicate something more than a common cold. The cough is not always present, so that this symptom does not indicate the extent of the disease ; and as children do not expectorate, the disorder in the chest may escape remark, until the dyspnoea suddenly conies on, and renders the danger imminent Then the pulse becomes extremely quick, and the severity of the attack is evinced by the manner in which the respiration is oppressed, and the circulation disturbed. This aggravation of symptoms often goes off for a time, leaving the child in a somno- lent state without much cough or quickness of pulse ; but if the breathing still continues quick, the dyspnoea returns after a while with increased severity, the frequency of the pulse is increased, stupor comes on, the lips become livid, and in this, or in some succeeding similar exacerbation, the child dies suffocated. The disease which resembles this more than the case before described, is that form of bronchitis which attacks old people and those of lax phleg- matic habit, and which bears the name of/>m- pneumonia nolha, or spurious inflammation of the lungs. Oppression of the breathing is here one of the earliest symptoms, and it is accompa- nied with a peculiar wheezing ; but all the symp- toms of inflammation are less acute than in the intense bronchitis before described ; and the fever that attends is of a lower and less phlogistic type. There is perhaps a greater loss of appetite, and more disturbance of the gastric function; the I tongue is loaded, and there is much thirst. The I pulse is quick and wiry ; the skin not much | raised in temperature except in the evening. The dyspnoea is liable to temporary exacerbations, which are often so severe as to prevent the patient from lying down, and are accompanied by extinction of the voice. The expectoration is scanty at first, but afterwards becomes very copious and frothy. The terminations of this form of bronchitis, which Dr. Badham appropriately denominates asthenic, are much of the same kind as those of the more violent inflammation ; but its duration is com- monly longer, and it has a great disposition to pass into a chronic form. Persons liable to pitui- tous catarrh, or who have habitually a cough with copious thin expectoration, when attacked by bronchitis, generally suffer from this form. Exciting Causes.—The usual cause of bron- . chitis is cold, particularly when conjoined with moisture, applied locally or generally, as for in- stance, by wearing damp clothing, or exposure to a cold, moist, variable atmosphere, especially after the body has been heated by exercise, crowded rooms, &c. But it appears that all sudden altera- tions of temperature from cold to heat, and cer- tain epidemic states of the atmosphere also, are capable of giving rise to bronchitic affections. Irritating gases and vapours may excite inflamma- tion of the bronchial membrane ; but it is of the slighter kind, and soon passes away, unless the cause be again applied. A much more severe bronchitis accompanies some of the acute erup- tive diseases, and frequently causes the chief danger that attends them. In some cases the eruption fades or is diminished, to the great in- crease of the bronchial affection, which is then announced by oppressive and dangerous dyspnoea. The inflammation of gout is sometimes translated in a similar manner in those predisposed to bron- chial inflammation, and the suddenness of the attack renders these cases the more dangerous. Physical Signs.—In investigating the patho- logy of acute bronchitis, we shall find that a much more accurate knowledge of the nature and extent of the disease may be obtained by a study of the physical signs than by any attention to the gene- ral symptoms alone. Inflammation of the mucous membrane of the bronchi at first causes tumefaction, and conse- quently a diminution of the caliber of the tubes. This, occurring in individual points, so modifies the passage of the air through them, that, as in a musical instrument, a sound is produced. This sound varies according to the form of the constric- tion and size of the tube ; but the general effect is, that on applying the ear to the chest we find the ordinary respiratory murmur accompanied by various whistling and wheezing sounds. These occasionally present a graver tone, like the pro- longed note of a violoncello or the cooing of a dove, and then indicate that some of the large 334 BRONCHITIS —[ACUTE.] bronchi are the seat of disease. To such modi- I fications of the respiratory sound, M. Laen- j nee gave the names of the sibilant rhonchus and the sonorous rhonchus. They are the symptoms of the earliest stage of bronchitis, and are often perceptible before the patient is aware of any suf- fering in the chest They prove moreover the fact, supposed by Dr. Badham and doubted by Dr. Hastings, that the dyspnoea of the early stage of bronchitis is caused rather by the state of the mucous membrane than by the redundancy of its secretion. Both the coarctation of the tubes by which air is scantily admitted, and the general thickening of the membrane by which the oxyge- nation of the blood is intercepted, appear to be the physical or pathological causes of the symp- tom in question. Percussion on the chest does not detect any loss of resonance. In the progress of the disease, the auscultator soon discovers the presence of a liquid secretion, by the bubbling sound occasioned by the passage of the air in the bronchi. This is the mucous rhonchus, and its presence announces the second, the catarrhal or secreting stage of the inflamma- tion. By practice the ear soon becomes enabled to distinguish the several sounds that are pro- duced in tubes of different sizes ; from these a pretty accurate estimate may be made of the situa- tion and extent of the inflammation ; and these circumstances bear a relation to the severity of the case. When the inflammation occupies only the large tubes, as is the case in common colds, the bubbles of the mucous rhonchus are large and uneven, and the sound of respiration may still be heard. But if the rhonchus is fine, and accompanies the whole of the respiratory act, it may be concluded that the disease is in the smaller bronchi; and if extensive, the function must seri- ously suffer. In this case there is sometimes a slight diminution of the resonance on percussion of the affected part The passage of the secre- tion from a thin to a consistent state, commonly called the ripening of the cold, has likewise its distinctive symptom. The bubbles of the mucous rhonchus first become more interrupted, and gra- dually give place to a clicking, or a sibilant sound, occasioned by portions of the inspissated mucus partially obstructing the bronchi. Sometimes the respiration of a portion of lung is entirely ob- structed by a pellet of this mucus in its princi- pal bronchus; and thus the dyspnoea occurring at this stage of the disease is explained. These several symptoms are liable to frequent change from the removal or altered position of the mucus consequent on coughing or expectoration; and it is useful to avail ourselves of this in our examina- tion ; for we may thus prevent the mistake of ascribing absence of respiration to peripneumony or any other cause. The varieties that we have before described as occurring in the progress and termination of acute bronchitis, depend on the character as well as on the extent of the inflammation. In the plethoric and sanguine temperament the inflammation is intense, and remains for a while dry; and the congested and thickened state of the membrane preventing the effectual arterialization of the blood, may in this stage cause dyspnoea. The copious secretion, however, that soon succeeds, and which appears to take place earlier in the dyspnoea of children, soon becomes an additional interruption to the function, and unless removed by expectoration or re-absorption, may soon amount to suffocation. The suddenness, as well as the abundance of its effusion, increases the danger of its effects; and this is the reason why cases of bronchitis suddenly supervening on a suppressed exanthema are amongst the most for midable. In old people, again, and those of a relaxed habit, there seems to be a serous infiltration accompanying the inflammation, which causes a greater straitening of the tubes in the first stage, than is usual in the other forms; and which is only relieved by a free secretion from their mucous coats. Morbid Anatomy. — The anatomy of fatal cases of bronchitis, as far as it goes, is in perfect accordance with what we learn from the phy- sical signs. The lungs do not in general col- lapse on opening the thorax; the escape of air being prevented by the obstructions in the bron- chi. These in most instances contain a quantity of frothy liquid, of the quality of the matter ex- pectorated before death. Not unfrequently it is mixed with bloody serum ; but this, as it is not perceived in the matter expectorated, has probably exuded from the surcharged blood-vessels at the moment of and after death. Purulent matter is also sometimes observed, and mostly in very acute cases, which have proved fatal within four or five days. The mucous coat presents an appearance of red injection, diffused, or in patches, of various shades from a bright crimson to a brown red. It is sometimes thickened, but rarely softened ; and never to the degree in which the gastro-intestinal mucous membrane is frequently found. Diagnosis. — The diagnosis of acute bron- chitis is to be deduced from the leading symptoms which we have given of the disease ; and if we avail ourselves of the physical as well as the gene- ral signs, its character will be quite distinctively defined. It is distinguished from pneumonia by the nature of the expectoration, which, al- though in severe cases often viscid, is less so than in pneumonia, and wants altogether that rusty tinge so characteristic of the latter disease : it is also distinguished by the clear sound on percus- sion of the chest, and the absence of the crepitant rhonchus or bronchophony. (See Pneumonia.) From pleuritis, the clear sound on percussion is sufficient to separate it. Both these diseases may, in some cases, be confounded with bronchitis without reference to these tests, but these never fail to decide its character. Prognosis.—The prognosis in acute bronchi- tis must depend on the extent of the disease. When the inflammation is partial, affecting a few bronchi only, as in common cases, and without much dyspnoea or fever, it may terminate in from six days to three or four weeks; and its disposi- tion to pass off is always indicated by the expec- toration becoming opaque and more consistent, and gradually diminishing in quantity. This change is always first observable in the mornings; the evening exacerbation restoring the thin glairy character to the sputa, even in cases tending to- wards convalescence. A relapse is marked by the expectorated matter becoming again transpa- BRONCHITIS —[ACUTE.] 335 rent and glairy, and this is always accompanied by an aggravation of the cough and other symp- toms. In the more extensive attacks of inflammation, where the dyspnoea is great and unremitting, and particularly where the fever was high in the be- ginning, the prognosis may be very unfavourable ; and if the acute symptoms have already yielded to the state of collapse, it is to be feared that the power of the system is insufficient to restore a function on which the disease has made a serious inroad. The extreme anxiety of the pallid coun- tenance, and a slight appearance of lividity, an- nounce the asphyxiating effects of this stage of the disease ; and the universal mucous rhonchus, with little or no respiratory murmur heard on the application of the ear or stethoscope to the chest, gives direct evidence of impending dissolution. There is sometimes accompanying continued fever a severe bronchial affection, which this ex- amination alone can detect. There is little cough, and the general symptoms so mask the dyspnoea that it may proceed to a fatal termination without being distinguished from the symptoms of general weakness and oppression that severe cases of con- tinued fever commonly present. (See Fever.) In severe bronchitis of children, likewise, the real amount of the danger can seldom be appre- ciated by the general symptoms in time for the effectual application of remedies ; but where aus- cultation discovers, from a universal mucous rhon- chus, that the inflammation is extensive, and occupies both lungs at once, great danger may be apprehended, whatever be the amount of dyspnoea and other symptoms at the time; for these fre- quently come on in paroxysms only, or are scarcely marked in the somnolent state in which the child lies during the remissions. The danger in asthenic bronchitis, or peripneu- monia notha, arises from the weakness and age of the patient; if these are great, there will be a great risk of the strength proving unequal to clear the lungs of the secretion that is so copiously poured out. The respiration of old people bears ill any sudden abridgment; for the more rigid tex- ture of their lungs does not, as in younger sub- jects, admit of additional or supplementary respi- ration in the healthy parts. (See DrspNOSA.) One of the most fatal forms of bronchitis is that super- vening on a suppressed eruption. Treatment of Acute Bronchitis.—1. The slighter cases of acute bronchitis are more fre- quently objects of domestic than of formal medi- cal treatment. When neglected, however, a com- mon cold may give rise to the most serious com- plaints; and we are far from subscribing to a pre- valent opinion to which even Laennec seems to lean, that it must always run its course. By anti- phlogistic diet, and a few simple means calculated to restore the secretions, and, if required, to cause revulsion from the inflamed part, a cold may often be checked in a few days, which if left to itself might run on for weeks, entailing on some sub- jects other and worse evils. The means which we have found most effectual are as follow:—At the first feeling of the cold, let a purgative be given, with two or three grains of ipecacuanha or James's powder. Let a hot pediluvium be used, the patient getting into a warm and well-covered bed immediately after, and promoting any disposi- tion to perspiration by a warm draught of thin gruel, barley-water, or any other mild diluent. If perspiration comes on and the purgative ope- rates well, the cold is sometimes already cured ; and it is only necessary to remain at home, and to abstain from animal food and wine next day, to prevent a return. If, however, perspiration do not follow, or if the cough has already come on. the disease gene- rally proceeds, and we must then endeavour to mitigate its severity, and bring it quickly thiough its course. If the patient cannot, or thinks it not worth while to remain in bed for a day or two, he should clothe more warmly than usual; for the susceptibility of the body is such as to render a very slight exposure enough to keep up the dis- ease, and abstinence from meat and all fermented liquors or spirits is at this period equally neces- sary. To loosen the cough and lead the bronchial inflammation to the stage of free secretion, small doses of ipecacuanha or tartarized antimony are often most effectual; and, although called a stimu- lant expectorant, squills, when combined with these, have always appeared to us to exert a bene- ficial effect: ten minims of the tincture with thirty of the vinum ipecacuanha?, and six or eight of liquor potassa?, given three or four times a day, seldom fail to facilitate expectoration and relieve the cough. Whether the alkali act by facilitating the absorption of the medicine, or by any specific action on the vessels of the bronchial membrane, we cannot determine ; but its effect in increasing the action of expectorants we have proved in a variety of examples. Should nausea be produced, the dose of the medicines may be diminished ; and if the cough is still troublesome at night, a little extract or tincture of hyoscyamus may with ad- vantage be added. This treatment is generally sufficient to relieve the tightness across the chest, which yields as the cough becomes loose ; but if the case is obstinate, it may be necessary to resort to a blister, or soma of the means which we shall presently recommend for the more severe forms of the disease. The inhalation of the vapour of warm watei may be sometimes useful ; but we have seen it in some instances increase the oppression ; and from its effect of determining blood to the part, we do not deem it so universally safe a measure in recent bronchitis as it has been represented to be. With still more force would we object to the cure by spirits or wine, as recommended by Laen- nec ; not that we doubt its occasional efficacy, but from the experience that where it does not cure, it greatly aggravates the inflammation. To- wards the termination, when the matter expecto- rated has become thick and loose, and all febrile symptoms are dissipated, animal food and wine may be indulged in with impunity, and even with advantage. At this period, too, if the disease shows a disposition to linger, much good may often be obtained by using some of the stimulant expectorants, as myrrh, copaiba, &c.; and if ne- cessary, the cough may be allayed by opium. This treatment will be noticed under the head of chronic bronchitis. There are very many remedies which are in common use for coughs, which it is impossible 336 BRONCHITIS —[ACUTE.] here to advert to. The safest are those which are simply demulcent; many are stimulant and nar- cotic, and often do mischief. Ipecacuanha lozenges is a remedy worthy to be named, as the conveni- ence of its form recommends it when more formal medicines are objected to; and although it is apt to cloy the stomach before sufficient quantity can be taken, it often proves as serviceable as the less agreeable compounds of the medicine. 2. The danger attending severe acute bronchitis renders far more energetic measures necessary; and these, although generally of the same class as those usually directed against acute inflamma- tions, must be exercised with more than usual discretion and caution. As long as the phlogistic state continues, with high fever, hard pulse, and great feeling of strait- ness and oppression in the chest, there can be no doubt of the propriety of bleeding more or less freely, according to the intensity of the symptoms, and the strength of the patient; but it is not pru- dent, as in pleurisy or peripneumony, to bleed to syncope, or to push the measure with an expecta- tion of very marked relief. From sixteen to twenty-four ounces may be taken at first in severe cases ; and the repetition of general bloodletting must depend on the state of the pulse rather than on other symptoms. If it is weak, or if the pa- tient is advanced in life, we must endeavour to subdue the symptoms by less violent means, such as local bleeding and medicines, rather than run the risk of destroying strength that is absolutely required for the act of expectoration. Cupping is generally to be preferred to leeches, as its effect is more speedy and more within con- trol ; and it is of considerable advantage to apply it to the part in which auscultation has discovered the greatest obstruction to the passage of the air. There is an objection which obtains so against blisters, as to exclude their use in many cases of the early stage of acute bronchitis ; namely, that before they rise, they always produce an irritating effect on the whole system, which is very apt to aggravate for the time the inflammation for which they are applied. This effect, however, varies much in different individuals, and in those whose skin easily vesicates under a blister, it is obviated by the serous discharge that immediately succeeds. In other instances, it is advisable to resort to other counter-irritants, and we give the preference to the tartar emetic. To make it available in an acute disease, we have found it necessary to excite the skin previously to its application, by means of a brush or coarse flannel, by applying a warm hand wetted with ether or camphorated spirit, or by a short application of a mustard poultice The tartar emetic should then be immediately rubbed in, cither in the form of a warm saturated solu- tion, or an ointment composed of one part tartar emetic to two of spermaceti ointment With these precautions we have rarely failed to excite a full pustular inflammation in as short a time as that required for the rising of a blister, with far less irritation to the system, and with decided relief to the pectoral symptoms. We have reason to believe that a minute quantity of the tartar emetic is absorbed into the system, as we have sometimes observed nausea succeed its use ; and this, instead of being injurious, as in the case of cantharides, is a part of the treatment which has been found most serviceable. This brings us to the subject of internal remedies. At the onset of the disease, the earlier the bet- ter, a brisk purgative should be given. Where the inflammation is high, calomel, with a grain or two of ipecacuanha, combined with jalap, scam- mony, or any of the active cathartics, is to be preferred, and followed by repeated doses of a saline aperient, containing a small quantity of tar- tarized antimony. This medicine proves useful not only as an evacuant, but as a sedative and diaphoretic, and the nausea, which it sometimes produces, is generally beneficial by modifying the secretion of the bronchial lining, and facilitating expectoration. For the same reason, a full emetic has been generally recommended, and is often de- cidedly useful; but it is better adapted to children, and to cases in which the bronchial secretion is profuse, than to the more inflammatory forms of the disease. For the relief of the dyspnoea and cough, those medicines are to be preferred which act on the vascular system. The sensation of dyspnoea is not to he looked on as one merely of discomfort, to be relieved by means which deaden sensibihtv, but as an indication of the inroad made on a vital function, which, if not restrained, must terminate in its destruction. To aid, therefore, the antiphlo- gistic measures that we have already recom- mended, it is proper to administer such medicines as are likely to moderate the action of the vessels and relieve the congested lungs. Tartar emetic, digitalis, and colchicum best answer this indica- tion, and we generally prefer the two former. The tincture of digitalis, in the dose of eight or ten minim«, with thirty or forty of the liquor an- timon. tartar., three or four times a day, is the form which we usually adopt. Of course it will be necessary to watch the effects of these medi- cines, and to diminish or discontinue the digitalis it the pulse become intermittent It will be of considerable advantage to increase the dose of tartar emetic; and if the dyspnoea continue, and the mucous rhonchus in the chest is undiminished, to persist in its use even should it excite vomiting; for its beneficial effects in peripneumony, to which bronchitis, in its severe form, really approaches very nearly, are sufficient to prove its power to restrain effusion and promote absorption. Dr. Badham strongly recommends this medicine in doses " frequently repeated, and increased till the maximum which the stomach can bear without vomiting is attained." Calomel and opium combined, and given in fre- quently repeated doses, as in other acute inflam- mations, are likewise sometimes highly beneficial; and we consider that their use is especially indi- cated, where, as is not unfrequently the case, the bronchitis is complicated with gastro-hepatic dis- ease. The opium should be in smaller proportion than usual, and is, perhaps, most safely given in the form of Dover's powder. Should the collapsed stage have come on, and the symptoms of debility show that the function of respiration has been already so much injured as to reduce the excitability of the system, it is necessary to resort to expectorants of the stimu- lating kind. Of these the best is carbonate of BRONCHITIS—[CHRONIC] 337 ammonia, which often enables a patient to expec- torate what in his weakness might be sufficient to suffocate him. We are disposed to think that this remedy is more than an ordinary stimulant, and acts in an especial manner on the bronchial mem- brane. The attenuating or solvent power of alkalies may with advantage be resorted to in the latter stage of bronchitis, when the matter of expecto- ration is very consistent, and, lodging in the bron- chi, occasions local absence of the sound of re- spiration, and, if copious, dyspncea. The liquor potassaa, in doses of ten minims, given with the vinum ipecacuanhae, is productive of obvious benefit. From what we know of the effects of the lobe- lia inflata in suffocative catarrh of the chronic kind, we should judge it to be worthy of a trial in the collapsed stage of acute bronchitis. Besides attempts to relieve the lungs of the load which prevents the penetration of air into (hem, another indication presents itself in this stage, which is to obviate the bad effects of black blood in the system ; for this it is, unquestionably, that gives that peculiarly depressed and adynamic type which precedes the fatal termination. Here, unfortunately, our experience fails us; and we feel the necessity of appealing to further researches of experimental physiology. 3. It remains for us to notice the modifications of treatment which the several varieties before described require. In the bronchitis of young children emetics are peculiarly serviceable ; for besides the beneficial effect they produce on the inflamed membrane itself, the muscular action of vomiting greatly assists expectoration, which can scarcely be effect- ed at this age. Purgatives, too, are generally of more marked utility than in adults, and, if re- peated, may frequently prevent the necessity for general bleeding. Dr. Hastings, however, highly recommends bleeding from the jugular vein; and in imminent cases this is probably the means most to be relied on. Dr. Badham suggests opening a vein in the foot, and immersing it for a few seconds in warm water, which causes blood to flow in sufficient abundance. In these cases, especially, we never can proceed confidently in the treatment without frequently appealing to the physical signs. The disease is so deceitful, (as Dr. Hastings remarks,) that except the universal mucous rhonchus, which nearly or entirely oblite- rates the respiratory murmur, no indication of the imminent danger can be discovered. In the asthenic form of the disease in adults, bloodletting is rarely admissible, and never to a great extent To restrain the secretion in the bronchi, and to rid them of it by means which do not greatly impair the strength, are here the ob- vious indications. Nauseating doses of tartar- emetic, or even larger, continued as in pneumonia until tolerance is established, purgatives, and deri- vatives, better fulfil these intentions. Blisters answer better here than in the more inflammatory disease, but to be effectual, they should be ample; and it is useful to give squill and digitalis (ten or fifteen minims of the tincture of each, three or four times a day,) during their operation ; for the secretion of urine is thus kept free, and there is Vol. I___43 2u less chance of irritation of the system by the can- tharides. Dr. Badham recommends assafcetida in the occasional aggravations of the dyspnoea, which he supposes to arise from a temporary spasm in the bronchi. The asthenic form of bronchitis leaves a greater weakness than the more inflam- matory; or rather, we should say, the weakness is the consequence of the habit of body which causes the disease to assume the asthenic form. It is therefore generally necessary to use tonics after it to restore the strength ; and if an irritable cough remains, without any excitement, opium may be resorted to to allay it. Change of air may some- times effectually answer both these purposes, and will generally be found a beneficial adjunct It is generally necessary to be peculiarly ener- getic in the treatment of bronchitis supervening on suppressed discharges and eruptions. Exten- sive counter-irritation, as recommended above, with tartar-emetic, would seem here to be espe- cially indicated. In case of repulsed gout, means should be taken to bring the gouty inflammation back to the limb by mustard poultices and hot water; but these measures are not solely to be depended on. II. Chroxic Bronchitis.—Chronic bronchitis presents as great a variety of form as the acute disease ; and from the complications into which it very frequently enters, it is less tractable in its nature. It is not an easy matter to define dis- tinctly the character which entitles a case of bron- chitis to the specific term chronic. The duration of the acute disease is very varied; and it is fre- quently renewed for such a length of time as might truly gain it the name of chronic. The distinc- tion which Andral gives, although by no means peifectly exact, is perhaps the best, inasmuch as it is founded on the pathology of the mucous membrane itself. As long as the expectorated matter remains glairy and viscid, uniting in mass, and without opacity, the inflammation is acute. Towards the termination of an attack of this kind, the sputa become opaque, and are expectorated in distinct masses, which, although consistent, are not very adhesive or glutinous. Sometimes, in- stead of diminishing and becoming more consis- tent, as when the disease is about to terminate, they remain in this state, or increase and become diffluent and heterogeneous in quality, without sensible increase of fever; and they then indicate inflammation of the chronic kind. Chronic bronchitis in its slightest form mani- fests itself only by habitual cough and expectora- tion, which are increased by certain changes of weather, and generally prevail most in winter and spring. It is most common in advanced life ; and in fact very few old people are perfectly free from it In its severer forms it is accompanied with dyspnoea, occasional pain in the chest and about the prsecordia, and some febrile symptoms, especially towards evening, palpitation, and disor- der of the digestive functions. The cough is sometimes very severe, especially at night, and the expectoration copious; and if these persist long, they seldom fail to waste the body and reduce the strength. The character of the expectoration is various Generally it consiste of a greenish-white mucus, or it may assume a muco-purulent appearance, 338 BRONCHITIS —[CHRONIC] and is often mixed with little thin pituita. Some- times the pituita are abundant, as in pituitous catarrh, and a few masses of brownish or ash- coloured mucus float in it Sometimes it is puru- lent, and streaked with blood; and in some cases it is real pus, presenting all the varieties that are seen in pus from other sources. In such instances there are generally a quick pulse and signs of hectic; and the disease tends to a fatal termina- tion, with night-sweats, emaciation, diarrhoea, and all the common symptoms of pulmonary con- sumption. The worst cases are usually those which succeed to repeated or severe attacks of acute bronchitis, whether of the intense or asthe- nic form. Exciting Causes.—When occurring in early life, chronic bronchitis generally follows hooping- cough, measles, small-pox, or some cutaneous eruption, and does not often succeed to an acute attack. A very distinct form of chronic bronchitis is excited by the habitual inhalation of air loaded with dust Needle-pointers, stone-cutters, those who powder and sift the materials for making china, and leather-dressers, are particularly liable to this affection. In these cases it usually begins with dyspnrea, which may continue for a conside- rable time before the disease declares itself. In the course of a few months, however, the dys- pnoea is increased, and accompanied by severe cough and a copious expectoration, sometimes mixed with pus and blood. Not unfrequently the cough brings on a profuse haemoptysis. At this time the constitution generally suffers much ; the pulse becomes quick ; thirst and fever attend ; the tongue is loaded ; and the aggravations of dyspnoea occasion lividity of the countenance. Unless these symptoms are relieved by remedies, and a total abandonment of the unhealthy occu- pation, they become worse; the expectoration increases to a great extent, and becomes more purulent; hectic, with night-sweats, succeeds; and the patient dies with most of the symptoms of tubercular phthisis. (See Artisans, Dis- eases of.) Physical Signs and Pathology.—The phy- sical signs of chronic bronchitis do not materially differ from those of the acute disease. The re- sonance of the chest on percussion is scarcely if at all impaired. The respiration is varied in its distinctness, being often louder than usual, but occasionally obscure, and accompanied with mu- cous rhonchus. This rhonchus is not universal over the chest, and seldom accompanies the whole of the respiratory act. It very rarely happens, as in the latter stage of acute bronchitis, that the respiration is completely interrupted in a part of the lungs ; and this proves that the mucus is in a more diffluent state, and yields to the air passing through the bronchi. Occasional sonorous and sibilant rhonchi prove the partial obstruction of the air-passages; and this may be either by a thickening of the mucous membrane, or by por- tions of thick mucus; but these symptoms are not so common in chronic bronchitis as in the dry and pituitous catarrhs. A remarkable feature in chronic bronchitis is, that dyspnoea is not unfrequently present to a considerable degree, when from the sound heard in the chest it is plain that the air enters the lungs as well as or better than usual; the respiration being distinct or even puerile. For a complete consideration of these apparently contradictory phenomena we must refer to the article Dyspnusa, and shall merely remark here, that the nature rather than the quantity of the bronchial mucus is probably the cause of the symptom in ques- tion. The continuance of inflammation has thceffect, ultimately, of altering the texture in the mucous membrane of the bronchi as in other parts. Its greater tenuity and simplicity of structure exempt it from a number of the changes which are inci- dent on the gastric and intestinal mucous mem- branes ; but it is nevertheless subject to softening, ulceration, induration, and thickening; and the effects that these produce on the caliber of the bronchi are worthy of our attention. Morbid Anatomy.—The mucous membrane is frequently found, on dissection, of a deep red colour, the redness being diffused or in patches. It is of a more livid or violet tint than in the acute disease, where it is usually brighter and more verging on brown. Not unfrequently, however, the membrane is quite free from this ; it is some- times even whiter than usual, and this in cases where there has been copious purulent expectora- tion. Softening does not occur to the extent to which it goes in inflammation of the gastric mu- cous membrane, and the simpler nature of the membrane explains this. (See Softening of Organs.) Ulceration is also rare, particularly in the smaller branches of the bronchi, except in those cases which arise from the inhalation of dust, in which the mucous membrane is generally ulcerated, often to a considerable extent; and the thickening and general alteration of structure are greater than in the ordinary cases of chronic bron- chitis. The ulcers are usually small, clean, and do not extend below the mucous and sub-mucous coats. Thickening of the membrane is a more common effect, and it sometimes occurs to a very notable extent, nearly obliterating the cavity of the tube. It is rarely uniform, but generally af- fects several points, particularly at the bifurcation of the tubes. Another and very remarkable state, produced by chronic bronchitis, is a dilatation of the bronchi. It is not of very 'unusual occurrence, and presents itself to the anatomist in different forms. Some- times a single tube is dilated at one or more points into a sac of various sizes, in some examples capable of containing a walnut. In other in- stances the dilatation is uniform, and extends to several tubes, which enlarge, instead of diminish- ing, as they divide. Thus a bronchus of the size of a straw is seen to dilate to that of a goose-quill. Sometimes several branches from the same tube are affected in this manner. The mucous mem- brane can always be distinctly traced from the undilated portions of the tubes, and usually with some difference in its texture. It is sometimes thickened; in other instances so extremely thin as to give the dilated portions the appearance of shining vesicles amongst the pulmonary tissue. Occasionally either the mucous membrane or the circumjacent coat becomes considerably indurated, so that the dilatations are rigid, and scarcely sus- ceptible of compression or dilatation; but the BRONCHITIS — [CHRONIC] 339 mucous membrane is more frequently softened, so that it can be scraped off by the nail. These dilatations, as the diseased bronchi in general, are frequently found full of pus, mucus, or whatever kind of matter has been expectorated before death. Laennec considers these organic changes to be produced simply by the thick mucus accumulating and gradually causing a mechanical distension of the tubes. But in this case we should discover more frequently an absence of the respiratory sound in the part: such a sign, although common in the latter stage of acute bronchitis, scarcely ever occurs in the chronic disease. We are more disposed to ascribe them, with Andral, to the al- tered texture of the membrane; but even this is only the predisposing cause. The physical cause of dilatation of the bronchi, we apprehend, is to be found in acts of respiration and cough exerting a degree of pressure on the softened membrane, greater than its elasticity can resist. Thus the forcible inspiration which sucfteds each fit of coughing acts with greater effect on these weaker parts; and again, the violent expiration of cough- ing brings an undue pressure on the same tubes, which, distended in one part, and partially ob- structed by the thickening of their membrane in another, are perpetually exposed to a straining influence. Induration, the effect of another de- gree of the inflammatory process, sometimes suc- ceeds, giving the dilated portions that rigidity that is occasionally noticed in them. The effect of these dilatations must be to obliterate the neigh- bouring cells, and to abridge the function of the lung. Accordingly the adjacent tissue is found, on dissection, to be dense, and deprived of its cellular structure; and when extensive, the dis- ease thus causes habitual dyspnoea. Diagnosis.—The characters of chronic bron- chitis are such as easily to distinguish it from all diseases except pulmonary consumption. The severer forms sometimes so closely resemble this disease, that it is impossible to distinguish them by the general symptoms; and even with the aid of auscultation and percussion the distinction is often very difficult. The presence of pus in the expectoration, which was formerly considered characteristic of phthisis, is, we have already seen, very common in chronic bronchitis; and in fact, that which occurs in the course of phthisis, proceeds more from the inflamed bronchial tubes, than from the tubercular excavations themselves. So likewise, hectic, night-sweats, emaciation, and diarrhoea, frequently accompany both diseases. When unattended with dilatation of the bron- chi, an attentive examination of the physical signs will, however, enable us to form a pretty sure diagnosis. It is in the absence of the signs of phthisis that we recognise the character of chronic catarrh; and as this negative test is weaker than positive proof, so it is necessary that it should be often repeated to produce certainty. If, after having repeatedly examined the patient, at differ- ent hours, during several weeks, there are found no gurgling cavernous rhonchus, no cavernous respiration, no pectoriloquy, and no constant ab- sence of the respiratory murmur, and of the sound on percussion, we may, with tolerable certitude, pronounce the disease to be simply pulmonary | catarrh ; and a still further multiplication of ex- aminations will remove all doubt. But if there be considerable dilatation of the bronchi, the same signs which are produced by tuberculous excavations in phthisis may likewise occur in chronic bronchitis. If the dilatation is produced at one part of the tube, and is of a rounded shape, it may be the seat of pectoriloquy and cavernous rhonchus, in the same manner as a tuberculous cavity of the same size: but if, as is the more common case, the tubes are more uni- formly and generally dilated, the vocal resonance in the tubes scarcely amounts to pectoriloquy, but is rather a loud bronchophony ; and the breathing is accompanied with a whiffing sound, more dis- tinct than the bronchial respiration of peripneu- mony. It is only by attention to the progress of such cases that they can be discovered not to be phthisical. A tuberculous excavation rarely re- mains stationary as these do, but enlarges and I gives a pectoriloquy of a greater extent; whilst other excavations are usually formed in other parts. Dilated bronchi rarely affect the sonoreity of the chest on percussion to the degree that the engorgement and infiltration about tubercular ex- cavations do; nor can they produce the other physical signs of large cavities. The most com- mon situations of dilated bronchi are in the scapu- lar, mammary, and lateral regions : the subclavian and acromian are the more usual seats of phthisi- cal signs. The only instance in which the sputa can assist in the diagnosis is, when they declare themselves phthisical by the presence of tubercle, or portions of the pulmonary tissue ; in other respects they may be exactly the same. A remarkable fcetor has been repeatedly observed in the sputa where the bronchi were dilated. It must be confessed that cases do occur, al- though rarely, which leave the most experienced auscultator in uncertainty ; but these are excep- tions of comparatively little practical importance, and hardly detracting from the utility of acscul- tation. For it need scarcely be remarked that dilatation of the bronchi is quite incurable; and I it is often connected with such extensive lesion of the bronchial membrane as would leave the prog- nosis the same as in phthisis. Prognosis.—The prognosis in chronic bron- chitis depends very much on its origin, and on its simplicity or complication with other disorders. When succeeding to an acute attack, and when unattended with much derangement of the gene- ral functions, it does not tend to a fatal termina- tion. Even should there be some purulent ex- pectoration and hectic, favourable circumstances will sometimes bring about a cure; and slighter forms, though obstinate and lasting for years, seem scarcely to have any effect in abridging life. But in its worst character, with constant dyspnoea, copious purulent expectoration, hectic, and ema- ciation, and especially if attended with symptoms of confirmed disease in the abdominal mucous membrane, or in the liver, it is nearly as fatal as phthisis itself. In these cases of complication, the bronchitis is frequently secondary ; and there : are abundant examples which prove that it may ' disappear entirely, if" the abdominal disease is of I a tractable nature, and yields to treatment. 340 BRONCHITIS —[CHRONIC] In many cases the prognosis must depend on the nature of the physical signs : the disease is itself an attendant on phthisis ; and if these do not establish with certainty that tubercles are not present, the case must always be considered of doubtful prospect. In the first stage of phthisis an extensive bronchial inflammation frequently attends, when the tubercles' are very numerous and generally dispersed, before the stage of soften- ' ing has come on. In all cases, therefore, which the history and constitution would indicate to be phthisical, the presence of a general mucous rhonchus, with partial dulness on percussion, must be considered a sign of the worst import, for a tubercular disease of this description gene- rally runs a speedy and fatal course. The cases of simple bronchitis that prove fatal are those in which the. mucous membrane has become so altered in its structure and function, that it permanently impedes the oxygenation of j the blood, and wastes the body by its secretion, > and the wearing efforts to evacuate it. These generally occur in old persons, and those already- reduced by fever or a severe attack of acute dis- j ease. [Bronchitis asthenica, Brtmchorrhcea.] One effect of the constantly imperfect oxygena- tion of the blood which attends bronchitis, is a ; stagnation and congestion of blood in the lungs and heart; hence organic diseases of the heart, and effusion of blood and serum, not unfrequently supervene to its long continuance. Treatment of Chronic Bronchitis. — In the treatment of chronic bronchitis, as of all chro- nic diseases, regard must be paid to the time I required for the cure, and the strength economised accordingly. Unless in case of a temporary in- crease of pulmonary congestion, or aggravation of inflammation, bloodletting is not admissible ; for besides its bad effect in adding to the weak- ' ness, which is one of the worst characters of the disease, it has but little power to control the action J of vessels under the influence of chronic inflam- mation. Those remedies are to be preferred which act on the extreme vessels, whether directly, in the diseased part, or by establishing a new action in another part of the system. The objection which we urged against blisters in the acute disease does not apply here; and they are often in a high degree serviceable. It is generally necessary to repeat them several times ; for few cases yield to a single application. In 6ome constitutions they produce a great prostra- tion of strength, and in others their beneficial effects do not continue: in such cases an effective substitute will be found in tartarized antimony, as recommended in the acute disease. The sup- purative inflammation that this excites is often more efficacious in removing inflammation from a deep-seated part than the irritation of a blister, the effects of which usually cease with the serous discharge. When it happens that a blister sup- purates, a more permanent benefit is obtained ; but keeping up the irritation by means of cantha- rides or savine ointment has not the same effect, and is more painful than salutary. Counter-irri- tation by tartar-emetic may, by attention, be regu- lated to any degree; and by slight re-application a constant succession of pustular eruptions may be continued for months, if required. From this measure, conjoined with internal medicines, we have seen the happiest results in cases of the mo.st formidable aspect; and we have scarcely ever known it fail to give some relief. It seems to mo- derate the irritation and secretion of the bronchial membrane, which often changes from purulent to mucous during its use; and it enables the system to bear a tonic and nutritive regimen without ag- gravation of the bronchial disease. It is by the success of a measure of this kind that a well- known modern empiric has gained a name famous enough to blind many to the gross ignorance with which he has applied it. [Dr. Graves (A System of Clinical Medicine, Dublin, 1843,) has recommended the formula published at page 222 of this volume, as an imi- tation of the liniment of this empiric, (St. John Long,) which, he affirms, is an easily manageable and efficacious remedy. A large portion of the chest may be sponged daily with the liniment, so as to keep up an ery- thematous state ofcthe surface.] The utility of expectorants in the chronic form of bronchitis has been called in doubt by the question — on what principle can they be pre- scribed, when the secretion is already redundant' But let it be remembered that the power of ex- pectorants is not confined to increasing the bronchial secretion ; they tend also to modify it, Thus, in acute catarrh, under the same expec- torant that at first tends to moisten the cough, the mucous secretion becomes consistent, di- minishes, and gradually returns to its healthy state. Ipecacuanha is certainly capable of pro- ducing this effect, and is perhaps the most gene- rally useful expectorant that we possess. In some cases it may be given with great advantage in emetic doses, repeated every two or three days. In some obstinate examples of the milder form of the disease attacking persons of robust habit, this practice has effected a cure. As an expectorant, it may be given in the dose of a grain or two of the powder, or twenty minims to Jss of the wine, repeated several times in the day, according to its effects, and combined with squill, colchicum, digi- talis, and opium, as the case may require. It is a useful adjunct to any expectorant medicine, and is only contra-indicated in case of profuse night-sweats. Squill is of decided utility in some instances of chronic coughs, but rather in cases which are slighter and unattended with purulent expectora- tion, ft is generally useful to combine it with an alkali; and a small quantity of opium may be added to prevent it from passing off too rapidly by the kidneys. Wherever the circulation is much accelerated, and the dyspnoea is distressing, the tincture of digitalis is very likely to afford relief; and those cases which simulate phthisis are frequently fit subjects for its use ; but it is necessary to watch its operations, both on account of its effects on the circulation, and its tendency to disorder the stomach and digestive organs. The same thing may be said of colchicum, which is highly spoken of by Dr. Hastings, who recommends the tincture in the dose of twenty drops three times a day, in- creased or diminished according to the effects. The lobelia inflata is a medicine less known BR0NCHITI3 —[CHRONIC] 341 in this country than it deserves. Its action seems to be of the same class as colchicum and squill, but it is more decided in its effects, and therefore likewise requires greater care in its exhibition. It may be tried first in the dose of ten minims of the tincture three times a day ; in many cases this may be increased to forty or fifty; but in others not more than five minims are borne with- out nausea, vertigo, and a feeling of faintness. From the manner in which it relieves the dyspnoea, it is probable that it operates as a sorbefacient as well as an expectorant It is especially service- able in those aggravations of chronic catarrh, which Laennec designates by the title of suffoca- tive, and which do, in fact, sometimes produce suffocation. In such cases, likewise, ammonia becomes a valuable remedy; and the one, in extreme cases, when suffocation is threatened, on which we must principally depend. From five to ten grains of the carbonate may be given in camphor mixture, and repeated, if necessary, every hour or half hour, according to its effects. In the weak and atonic cases, without profuse expectoration, it is a useful adjunct to squill, ipecacuanha, and other medicines, instead of the fixed alkalies; and, con- joined with assafcetida or musk, it is well suited to diminish the convulsive character of some habitual coughs, which are very apt to wear down the patient, and deprive him of his nightly rest. [Tar-water was at one time greatly extolled in pulmonary affections, and, among the rest, in pulmonary catarrh, and in chronic bronchitis; and since the discovery of creasote — the main active ingredient in tar-water — fresh trials have been made with it. It is occasionally of service, where the ordinary excitant expectorants are indi- cated. Creasote itself has been given in the same cases; but it does not seem to possess more virtue than tar-water.] It would be endless to go through all the re- medies that have been extolled as effectual expec- torants in chronic bronchitis. All the balsams and gum-resins have enjoyed this reputation, and fallen again in disrepute : some, as copaiba and myrrh, have been resumed by some practitioners, and not without r< ason ; but their utility is limited to cases of the atonic kind. Myrrh we have found really serviceable, particularly after a course of the other expectorants, when its grateful and tonic effects on the stomach give it an additional recom- mendation. Copaiba frequently disagrees with the stomach; but when it is well supported, it often restrains and modifies the bronchial secre- tion. Neither of these medicines is eligible when fever or vascular irritability is present; and it may be considered a matter of doubt whether they do not act rather as general stimulants than pe- culiarly on the bronchial membrane. [The acetate of lead has been thought worthy of great reliance in bronchitis accompanied by profuse secretion ; its administration being limited to the period of the disease in which the secretion is excessive. The dose should not exceed twelve grains in the day, to the adult] There is a class of remedies from which, if they were better known, much good might be expected ; those, namely, directly applied to the diseased membrane itself by inhalation. The 2d* vapour of water does not seem to possess any property to recommend it in chronic bronchitis, unless it be in those rare cases of deficient or very viscid secretion, where it may he of some use in relaxing the vessels and facilitating ex- pectoration. Whether combining it with chlorine or with the vapour of iodine, as lately practised in Paris in consumptive cases, may be of any avail in this affection, we want data to determine. It is probable that they can scarcely be exhibited for a sufficient length of time to be effectual in a very diluted form ; and when stronger, they decidedly irritate and prove injurious. The diffusion of the vapour in the air of the apartment, as has been done with tar, is a pre- ferable method, as it ensures the constant appli- cation of the remedy without extra fatigue to the patient The inhalation of tar-vapour has had repeated and extensive trials since Sir A. Crich- ton directed the attention of British practitioners to it; and although its utility in phthisis has not been confirmed, many have testified to its bene- ficial effects in certain cases of chronic bronchitis. As it is of a stimulating nature, it proves useful only in cases free from irritability or from ten- dency to active inflammation ; and it is important to watch its effects when first employed, and to diminish or withdraw it altogether, if it decidedly aggravates the cough, and quickens the circu- lation. [Iodine has been administered;—at times, alone; at others, associated with conium, as advised by Sir Charles Scudamore, in tubercular phthisis (q. v.) ; but whilst some extol it highly, others have not observed the least benefit from it. Conium, and other narcotics, have been used in the same manner — twelve or fifteen grains of the extract being diffused in an inhaling apparatus, and the vapour drawn into the lungs for a quarter of an hour, once or twice a day.] Another class of remedies may in many in- stances of chronic catarrh be judiciously conjoined with those already noticed ; those, namely, that deaden sensibility, and allay that mobility of the muscular system which greatly increases the length and frequency of the fits of coughing. The most powerful of these narcotics, of course, is opium ; but on account of its tendency to check secretions and increase local congestions, it can- not with propriety be given alone, unless occa- sionally, for the sake of obtaining a night's rest. In this case the acetate or sulphate of morphia, ! or any of the acid preparations of opium, such as i Battley's liquor opii sedativus, is to be preferred ; and these will generally be found to be safer me- dicines for habitual use, in combination with squill and ipecacuanha or other expectorants, than the tincture or solid form of opium. The tinc- tura camphorse composite is also a very useful narcotic in chronic coughs of the less inflamma- tory kind. There are other narcotics of very high utility, and which are free from the disadvantageous pro- perties that opium sometimes manifests. At the head of these may be placed conium, the extract of which, in the dose of four or five grains three or four times a day, very signally relieves cough and irritation of the chest. Dr. Paris, who greatly extols this remedy, recommends the dose to be 342 BRONCHITIS —[SUMMER.] inert «Kd until it produce some giddiness, tremor, and w^u^ea, or a heavy sensation and tightness in the fo-cnead; unless some of these sensations are produced, he considers that the remedy has not had a fair trial. It is always advantageous to combine it with ipecacuanha; and the extract of hyoscyamus is indicated where an additional nar- cotic power is desired. The extract or leaves of belladonna, in the dose of a grain or two, we have found a useful adjunct where dyspnoea is present. The tincture of digitalis may be used with the same view ; and either of these medicines is to be preferred to the hydrocyanic acid, which, notwithstanding the praises lavished on it, must be considered at least a very uncertain remedy. Besides these means, directed against the local disease, it is of the greatest importance to attend to the state of the functions in general. When- ever any fever attends, the daily exhibition of a saline purgative is advisable. In the more atonic cases, if aperient medicine be required, a com- pound colocynth or aloetic pill is to be preferred; and where the cough shows a convulsive charac- ter, we have seen the greatest advantage result from the daily use of the pil. aloes et assafcetidffi combined with ipecacuanha. Should there be, as there very often is, any complication with abdominal disease, it is of the first consequence that this be not neglected. Thus, when pain of the right side and shoulder, with fulness and tenderness in the right hypochondri- um, stools of unnatural colour, a foul tongue and turbid urine, discover disordered function of the liver and alimentary canal, it will be proper to put the patient under such an alterative course of blue pill and the like medicines as may be best calculated to bring back the healthy action of these important viscera. Again, where a florid tongue, tender epigastri- um, frequent thirst, dry skin, and nightly acces- sion of fever, indicate that the disease extends to the mucous membrane of the stomach and bowels, it is quite apparent that many of the remedies directed against the bronchial disease will not be borne or will prove injurious, until the gastritic disease be relieved by leeches and blisters to the epigastrium, castor oil, the mildest alterative ape- rients, and warm baths, with the most rigid regu- lation of diet. For more ample directions on this head we must refer to the several articles Gastri- tis, Dtspefsia, &c. Whether these diseases be primary or secondary is a consideration of less consequence than that, as long as they continue, the action of all remedies on the bronchial disease must be uncertain or prejudicial. Thus it is that even digitalis and colchicum may prove stimulant until the gastritic disease be subdued. If due attention be paid to the removal of such complications, and if the disease do not present a decidedly inflammatory character, the weakness of the system may be combated by tonics, espe- cially the sulphate of quinine. In case of pro- fuse perspirations, these are scarcely to be dis- pensed with, and may properly be combined with sulphuric acid. The diet in all cases of chronic bronchitis should be mild and simple in its nature. Farina- ceous and milky food is that best adapted to the plurality of cases, particularly when accompanied by gastritic disorder; but in those cases that re- quire nutrition in a smaller bulk, simple animal food is not to be withheld. Notwithstanding the eulogy bestowed by Laennec on the spirituous treatment of chronic mucous catarrh, we consider spirits and all fermented liquors in themselves as decidedly injurious; and they are only to be ad- mitted in a very few cases, where their assistance in the digestive process is absolutely required. It is scarcely necessary to insist on the import- ance of avoiding extremes and sudden transitions of temperature, improper clothing, and all those circumstances that are in themselves frequent ex- citing causes of the disease : when re-applied, they must necessarily prolong it; and not a few instances are met with where, owing to the nature of our climate, it is impossible sufficiently to avoid them. In these cases, in spite of the most care- ful administration of these remedies, the disease persists ; but a perfect cure is effected by simple removal to a more genial climate. This is, per- haps, the most effective remedy that can be resort- ed to; and where the circumstances of the patient do not permit him to adopt it to its full extent, a change of air to the distance of a few miles may often be productive of good. The careful regu- lation of the air in his apartments must be his resource in the winter months. (See Climate and Phthisis.) It is of importance to attend not merely to the temperature, but also to the hygro- metric state of the air; and it may be useful in some cases to follow Dr. Paris's plan of diffusing the vapour of water through the room during the prevalence of those dry easterly winds which irri- tate the mucous membranes, and aggravate the cough. Of the means which may be called prophylac- tic against bronchitis, that of sponging the chest daily with salt water, or vinegar and water, de- serves warmly to be recommended. If this, which may be practised by the most delicate, and the cold plunge or shower-bath for those stronger, were more commonly resorted to, the number of pulmonary invalids would be greatly diminished. [But few invalids, who are subject to bronchi- tis, can bear with impunity the contact of very cold air with the pulmonary mucous membrane; hence they are compelled to breathe through folds of gauze, or to hold a handkerchief to the mouth, whenever they are exposed to it. An instrument has been invented by Mr. Jeffreys, called a Respi- rator, which consists of several strata of fine wire, through which the air can pass with facility ; and, in its passage, have its temperature modified, so that no irritation is produced in the lungs. The invention is ingenious and useful.] C. J. B. Williams. [III. Acute Epidemic Bronchitis. (See In- fluenza.) IV. Summer Bronchitis.—This singular af- fection has received various names. It has been called Summer Catarrh, Hay Asthma, Hay Fe- ver, and Rose Catarrh, and is met with in the summer and autumnal seasons, both in this coun- try and in Europe. It has received those various names as indicative of the period of the year at which it occurs, or of the causes that give rise to it BRONCHITIS —BRONCHOCELE. 343 Diagnosis.—The most common symptoms are itching of the eyelids, and, at times, of the inner canthi of the eyes, with irregular attacks of violent sneezing, sense of weight in inspiration, and, at times, considerable dyspnoea, copious discharge from the Schneiderian membrane, redness of the conjunctiva, and sense of weight in the forehead, with suspension—partial or entire—of smell and taste during the continuance of the disease. The exacerbations have been commonly observed to supervene in the morning, a short time after ris- ing; but frequently they appear several times in the course of the day. Many letters have been published from patients descriptive of their suffer- ings from this strange malady. (Elliotson's Prin- ciples and Practice of Medicine, Rogers's edit, p. 720: Lond. 1839; and the writer's Practice of Medicine, 2d edit, i. 273 : Philad. 1844.) The attacks appear at times with such regularity, that individuals have made it a point to transact im- portant business prior to a certain day of the year; being aware, from their experience, that on that day they are almost certain of the presence of their annual visiter. The functional phenomena of the disease do not place it, as one of its names would import, under nervous or spasmodic asthma. It appears to consist essentially in inflammatory irritation of the mucous membrane of the eyes, nose, and the whole respiratory apparatus, — the dyspnoea originating in this cause. It is rather a form of chronic or subacute bronchitis, and scarcely to be regarded as a combination of catarrh and asthma, as it has been by some. Causes.—The prevalent idea is, that summer bronchitis arises from vegetable matter diffused in the atmosphere; that it is derived from the flowers of certain plants, and that, in a great number of instances, it comes from grass or hay ; but it is against the notion of the effluvia from hay being a common exciting cause, that haymakers them- selves are said to be entirely free from it; and that it is often met with in towns, where such effluvia, if they exist at all, cannot be in any con- siderable quantity. The rarity with which the disease is seen suffi- ciently proves that the predisposition lies in idio- syncrasy, which would seem at times to be derived from progenitors. When such predisposition ex- ists, the smell of hay may act as an exciting cause; but in other instances it may be an emanation of a very different kind. The odour of ipecacuanha is one of the most frequent excitants : with others, the same effect is induced by the smell of the rose, the bean-flower, the guinea-pig, &c. &c.; and the case of an English nobleman is recorded, who is affected with sneezing and asth- matic symptoms if he touches a hare, or rather the fur of a hare. Cases of periodical bronchitis, analogous in their character to hay asthma, occa- sionally occur in which hay can by no means be ranked as a cause. An interesting example of this kind has been given by the writer else- where. (Practice of Medicine, i. 275.) Treatment.—It does not appear that much advantage is derived from medicine in this disease. The cold shower-bath has been regarded as the best prophylactic, especially when associated with the internal use of the sulphate of quinia and the sulphate of iron, which, although not wholly com- patible chemically, form a compound that has been productive of advantage ; two or three grains of the former and one grain of the latter being given three times a day. A journey to the seacoast has likewise been advised, and, from change perhaps, the paroxysm has been prevented. When the disease is fairly formed, it runs its course greatly unmodified by remedies. It does not bear deple- tion well nor a sedative course ; yet a drachm of the tincture of lobelia three times a day is assert- ed by a recent writer to generally afford relief; whilst another has found a cup of strong coffee without sugar or milk the most successful remedy. Too rigorous a diet and too free exposure to air have been prejudicial to almost all. Distressing as the affection is, it is consolatory to know, that during the autumn it gradually ceases and disappears,—too often to recur at the same period in subsequent years. The efforts of the practitioner can only palliate the urgent symp- toms, and even in this respect his powers will be found very limited, and his attempts to afford re- lief too often either wholly nugatory, or produc- tive of unexpected aggravation of the symp- Robley Dunglison. Bronchitis Asthenica. (See Bronchitis, Chronic)] BRONCHOCELE means, literally, a swelling of the throat, from (ip6y%os, guttur, and kijXi?, tu- mor ,- and, in fact, every indolent tumour on the fore-part of the neck, until recent times, passed under that denomination. Modern physicians, however, have confined the term to a chronic en- largement of the thyroid gland, sometimes com- plicated with a morbid growth in the surrounding structure. There is no precise name for the dis- ease in this country ; but, from being more com- mon in Derbyshire than other parts, it has some- times been called the " Derbyshire neck." In Switzerland, where in many parts it is endemial, it is called goitre, probably a corruption of guttur, and is generally an attendant on that humiliating state of body and mind known by the name of cretinism. There is, however, by no means an invariable fellowship between the two diseases, although Professor Fodere has ascribed the men- tal imbecility to the state of the gland, (Traite sur le Goitre et le Cretinisme, 8vo., Paris, an 8,) and Dr. Rush, of Philadelphia, has even deduced a theory respecting its uses from this supposed | causation among other things, (Medical and Phy- j sical Journal, vol. xvi. p. 208.) The tumour, as we have stated, is of a chronic or indolent nature, increasing gradually, and often continuing for many years, or even a whole life- time, without affecting the general health. It usually appears in early life, and is much more common among women, especially those of a lax j fibre, than among men; insomuch, that in this I country it is very rarely met with in the male sex. [It would seem, however, that in Switzerland, and in some parts of India, where the disease prevails extensively, the proportion of males is greater.] In all the cases admitted at the Hampshire Coun- ty Hospital during the last ten years, amounting to forty-nine, the patients have, with only one ex- ception, been women. We are informed by Dr. 344 BRONCHOCELE. Forbes, that out of seventy pntients treated at the | Chicester Dispensary and Infirmary during the last nine years, only two have been males. It is also worthy of notice, that both the latter cases occurred in boys of a very feeble and feminine habit of body, and very backward for their years. The disease has, in some instances, been observed to make its first appearance during parturition, and, in other cases, to have made rapid progress during gestation or suppression of the menses, (M. Brun. These sur Bronchocele. Paris, 1815.) The swelling generally embraces the whole gland, but is sometimes confined to the lateral lobes, or the middle lobe, separately. It is usually soft and rather flabby to the touch, though somewhat un- equal in that respect, and is for the most part free from pain and of a natural colour. It varies in shape, at first presenting but little outline, and while of moderate dimensions, possessing a more rounded and compact appearance than it afterwards preserves. When of considerable size it has a pendulous form, not unlike the dew- lap of a turkey-cock, the bottom being the largest part. In point of magnitude it varies still more remarkably; often remaining through life of no very conspicuous size ; in other cases increasing to a degree of hideous deformity : sometimes it rises as high as the ears. Alibert mentions one instance in which it descended to the middle of the sternum; and another in which it was of a tapering cylindrical shape, and reached to the mid- dle of the thigh, (Nosologic Naturelle, t. i., pp. 466-468. Paris, 1817.) In cases of great en- largement it impedes respiration, deglutition, and the return of the blood from the head, by its pres- sure ; thus occasioning hoarseness, wheezing, flushings of the face, headach, giddiness, and, in some instances, even death. In these extreme cases there are occasional pains in the tumour, and the skin becomes of a livid appearance, with the veins on its surface much swollen. The late Dr. Parry, of Bath, often observed bronchocele to follow diseases of the heart, epilepsy, and other maladies in which the blood is propelled with ex- cessive momentum to the head, (Elements of Pa- thology, p. 187, 8vo. Lond. 1815.) Flajani has seen it accompanied with palpitations and irregu- lar and intermitting pulse; and he believes that fatal disease of the lungs has been induced by the consequent disorder in the pulmonary circu- lation, (Collezzione d'Osservazioni e Riflessioni di Chirurgia, t iii. p. 283, 8vo. Roma.) On dissecting the tumour, Hunter and Baillie found it to contain cells with a fluid more or less viscid; and Mr. Benjamin Bell states this to be frequently the nature of the disease. "These cells," says Baillie, " vary in their size in differ- ent parts of the same gland, and in different swellings of the same kind in different individuals. Some of them are so large as to be able to con- tain a small pea, but most of them are of a small- er size. The viscid fluid, when the gland has been preserved some time in spirits, is changed into a transparent jelly. From this account of the morbid change of structure which takes place in bronchocele, it seems not unreasonable to sup- pose that the swelling depends upon a vitiated and increased secretion in the gland. The secre- tion, being in large quantity, gradually distends the cells, increasing thereby their capacity, and this enlargement of the cells forms the general swelling of the gland, (Morbid Anatomy, 8vo., pp. 87, 88.) The tumour is sometimes steatoma- tous. It is rarely found to contain purulent mat- ter. Occasionally it has been in part converted into cartilage or bone. Dr. Hedenus, of Dresden, states that he has almost uniformly found this to be the case, (Graefe's Journ. der Chir. b. ii. Ber- lin.) Sometimes the enlargement of the gland is a true sarcoma. Dr. Mason Good names it sar- coma cellulosum, or cystose tumour, and states that it generally consists of " oval cells, currant- sized or grape-sized, containing a serous fluid, sometimes caseous," (Study of Medicine, vol. v.) Celsus has briefly and accurately described the appearances on dissection in these words : " Mo- do caro hebes, modo humor aliquis, melli aqureve similis, includitur ; interdum etiam minutis ossi- bus pili immisti," (Lib. vii., cap. 13.) [Occasionally, the whole organ is transformed into an osseous capsule, filled with various kinds of matter, especially the jelly-like, the suety, and the meliceric. Dr. Gross (Elements of Patho- logical Anatomy, p. 16 : Boston, 1839,) states, that he has a specimen of the kind in his cabinet: one of the lobes has almost disappeared; the other is converted into a firm, solid capsule, as hard as bone, though scarcely a line in thickness. On sawing through this osseous tumour, which does not exceed the volume of a hen's egg, he found it filled with a white, lardy, friable sub- stance, not unlike semi-concrete cheese.] There have been instances in which the tumour has exhibited a complication of almost every di- versity of structure. De Haen relates a striking example of this, in a person who died of dropsy from visceral tumours. " In cadavere horrendara mole thyroidseam glandulam nactus, publice dis- secui. Mecum auditores mirabantur nullum fere genus tumorum dari, quiii in hac sola thyroidal in- veniretur. Hie enim steatoma, ibi atheroma, alio in loco purulentus tumor, in alio hydatrius, in alio erat coagulatus sanguis, fluidtis fere in alio, imo hinc glutine loculus plenus erat, alibi calce cum sebo mista," &c, (Rat. Medendi, pars vii. p. 285.) These circumstances countenance the opin- ion that the same causes may produce most of the different kinds of tumour, the modifications depending upon the difference of site, habit of body, idiosyncrasy, &c. There are some other diseases with which bron- chocele might be confounded, and which have indeed at times been included under the same name. Thus, the thyroid gland is occasionally attacked with acute inflammation, though, per- haps, less liable to it than most other glands of the body. In such cases, however, the swelling is more rapid in its progress than in bronchocele, but does not attain so large a size : it is firmer to the touch, painful on pressure, and the disease is much more liable to terminate in suppuration. Again, schirrus of the gland may be distinguished from goitre by its great hardness, by occasional darting pains in the part, and by its generally occurring in advanced age, and seldom attaining to any great size. Alibert, however, states that he has seen an instance of true goitre terminating \ in cancer. (Nosologic Naturelle.) Aneurisms, BRONCHOCELE. 345 though they do not frequently occur in that j situation, might possibly be mistaken for broncho- cele 5 but they may be distinguished by their sud- den appearance after violent exertion, particularly in coughing or laughing, by their being soft and compressible, by their situation directly in the course of the carotid arteries, and by their strong pulsation. The lymphatic glands are sometimes so enlarged, in scrofulous cases, as to form tumours j of considerable size in the course of the trachea; they may, however, be distinguished from this j disease by their greater tenderness on pressure, sometimes by an evident sense of fluctuation, by their being accompanied with swellings in other parts, and by the state of the general health. In some instances, indeed, the thyroid gland has, on dissection, been found in a natural state, the whole of the tumour consisting of a diseased state of the lymphatic glands and cellular membrane sur- rounding it. Instances have occurred of tumours arising in consequence of the lining membrane of the trachea being forced out between the cartilages in violent fits of coughing, sneezing, laughing, or other exertions of the lungs. Cases of this kind are styled the real bronchocele by M. Larrey. They might, perhaps, with more propriety, be called hernia gutluris or hernia bronchialis, names which have been sometimes given to the common bronchocele. Certainly, however, this is not the disease which has been usually known by the name of bronchocele, and to which the term is now almost universally confined; and as we are not at present considering the nosological propriety of the designation, we would include such cases among the spurious goitres. Their most characteristic symptom is the complete dis- appearance of the tumour when compressed. The voice, too, is almost entirely lost, and the respira- tion performed with the mouth wide open. Larrey observed it most frequently among the blind peo- ple who are employed by the priests to chaunt at the tops of the minarets in Egypt; and he met with two cases of it in subaltern officers, who had for a considerable time been employed as military instructors. (Medical Gazette, vol. vii. p. 88.) Dr. Barton, in his memoir on goitre as it prevails in America, states, on the authority of Fodere, that air has sometimes been forced, in like manner, into the substance of the thyroid gland and the surrounding cellular membrane. (Medico-Chi- rurg. Trans, vol. xi. p. 242.) Whether this be so or not, it appears certain, from the statement of various authors, that the tumour is often in- creased on exertion of the lungs. Goitre may also be confounded with encysted tumours situ- ated in the course of the trachea. The latter, however, are generally rounder, more moveable, more elastic, and more equal to the touch : they are sometimes diaphanoua, and fluctuation may often be perceived on pressure. The period of life, too, may at times assist in the diagnosis. In addition to these spurious or complicated cases of bronchocele, there are other instances in which the gland itself is healthy, and the tumour consiste of condensed cellular membrane, sometimes inter- spersed with cysts. Sometimes a cyst, filled with matter of a pultaceous or purulent nature, has been formed around the gland; and there have Vol I.—44 been cases in which the enlarged gland was sur- rounded by a yellow fatty mass. We are so completely unacquainted with the uses of the thyroid gland, and consequently with the peculiar causes of disease in it, that it is not wonderful, perhaps, that there should have been so much conjecture and discordance of opinion with respect to the origin of bronchocele. What- ever may be the primary source of the disease, there is much reason for supposing that, once established, it is often continued in families by in- heritance ;* or, at least, that a strong predisposi- tion to it is in this manner acquired. Thus we have known a woman with goitre, whose grand- mother, father, paternal aunt, and cousins, also had it; although they did not all live in the same place, and no other person in their neighbour- hood was affected with the disease. Similar in- stances have presented themselves to others; (Thomas's Practice of Physic, p. 573, 2d ed.,) and it is well known that where cretinism pre- vails, infants are often born with goitre. In such places, therefore, the effect of intermarriage among the inhabitants is not to be overlooked, as tending to spread and perpetuate it The disease has sometimes been attributed to a scrofulous taint in the constitution; but as it is only met with in particular districts, as it is not always accompa- nied with swelled lymphatic glands or disordered general health, and as the tumour in bronchocele is scarcely known to suppurate spontaneously, while, on dissection, it has mostly been found of a totally different nature from strumous swellings, the conjecture must be abandoned. It has been held by some that bronchocele arises from a defi- ciency of nutritive food; and Dr. Mason Good countenances this opinion. He states, that on a visit to Derbyshire "he found a much larger number of the poor affected with this disease than he had ever seen before, while the rich escaped ; and he found, also, that by far the greater part of those who were labouring under it were not only exposed to all the ordinary evils of poverty, but derived their chief diet from that indigestible and innutritive substance the Derbyshire oaten cake, which," he adds, " is probably the chief cause of all the glandular and parabysmic enlargements which are so common in that quarter." (Study of Medicine, vol. v. p. 416.) That insufficient nutriment may concur with other causes in pro- ducing the disease, is probable enough; but that this is its principal origin is an untenable idea ; since, in countries where the malady prevails endemically, the rich are by no means exempt from it. There are other circumstances besides diet, too, capable, it may be, of producing it, and to which the poor are more exposed than the rich, as we shall presently show. And lastly, the oaten diet, to which Dr. Good attributes the dis- ease in Derbyshire, is still more exclusively used in Scotland, where the disease is of rare occur- rence. It was long supposed, from goitre prevailing so generally in mountainous countries, that it arose from the habitual drinking of snow-water. This notion seems to have been derived from Pliny, * Dr. [Sir] James Clark. Notes on Climate, Diseases, Sec in France, Italy, and Switzerland, p. 109, London, 1620. 346 BRONCHOCELE. (Lib. ii. cap. 37,) and copied by succeeding writers, because it tallied with their doctrines of cold and crude matters. When it is considered, however, that no such cause exists where the dis- ease prevails in this country ; that it is rare in Scotland, though common in many parts of the south of England; that the Swiss, who live con- tiguous to the glaciers, and drink no other water but what flows from the melting of ice and snow, are free from the disorder; and that it is never met with in Greenland, where snow-water is the common drink ; while in Sumatra, where snow is never seen, it is of frequent occurrence ; it is evi- dent that we must look for some other cause. Dr. Richardson, indeed, in his journey with Capt. Franklin to the shores of the Polar Sea, ascer- tained that at Edmonstone, where, it seems, a residence of a single year is sufficient to render a family bronchocelous, the disease is seldom met with in those who drink melted snow, but is al- most exclusively confined to those who use the river water. (Franklin's Narrative, &c. pp. 118, 119.) This circumstance, on the other hand, countenances the opinion that goitre arises from certain calcareous or other impregnations of the water in common drink. The same view is strongly favoured by Dr. Bally, a native of a goitrous district in Switzerland. He says, « Bron- chocele appears to me to be produced by certain waters which issue from the hollows of rocks, trickle along the cliffs of mountains, or spring from the bowels of the earth. That this is the case I may instance some fountains in my own coun- try, (Departement du Leman au Hameau de Timet,) the use of whose waters will, in eight or ten days, produce or augment goitrous swellings. Such of the inhabitants of the above village as avoid these waters are free from goitre and cre- tinism." (Diet des Sciences Medicales, t viii.) Dr. Coindet states that the use of hard water, or the pump-water of the lower streets of Geneva, brings on the goitre very speedily, (Observations on the remarkable effects of iodine, &c. p. 7;) and Dr. Manson attributes the prevalence of the dis- ease in Nottingham to the same cause. (Medical Researches on the effects of iodine, pp. 4, 5, 8vo. London, 1825.) The frequency, also, of its oc- currence in the valleys of the chalky districts in Hants and Sussex is certainly in favour of these views. In the central parts of Hampshire, how- ever, we have almost uniformly met with it in the valleys only; and even there its frequency is by no means so great as, in our opinion, to justify the conclusion that it arises solely from the nature of the waters. That it should prevail to a far greater extent in these vales than in many much more confined valleys in the more northern parts of the island, may possibly arise from the greater moisture of the soil where the substratum is chalk : and partly, perhaps, from the greater de- gree of miasmatic evaporation occurring under a more southern sun. [A modern writer on bronchocele, Dr. Inglis, (Treatise on English Bronchocele, London, 1838,) affirms, that the presence of magnesian limestone always implies the co-existence of the disease; and Mr. M'Clelland, who had numerous oppor- tunities for observation in India, (Some Inquiries in the Province of Kemaon relative to Geology, &c, Calcutta, 1835; cited in British and Foreign Medical Review, for July 1S39, p. 103,) states, that in the course of his professional inquiries, which extended over 1000 square miles, and were prosecuted without any regard to theory, no in- stance occurred, in which goitre prevailed to any extent, where the villages were not situate on or close to limestone rocks. Still, there are many places, as the Vallais, in which there are.no lime- stone formations ; and in other places, where the disease prevails, the water contains no calcareous salts.] Whether or not the disease be necessarily con- nected with the impregnations of the water in those places where it prevails, every circumstance in its history tends to prove almost beyond a doubt, that it is induced by the agency of some one or more physical causes upon the constitu- tion. Larrey observed that almost all the inha- bitants in the valley of Maurienne were affected with goitres, (Mem. de Chir. Mil. t i. p. 123 ;) and Postiglione remarks that, in Savoy, Switzer- land, the Tyrol, and Carinthia, there are villages in which all the inhabitants, without exception, have these swellings; the form and position of which are considered as indications of beauty. (Memoria sulla natura del gozzo, p. 22.) Pro- fessor Fodere, in his journey to the maritime Alps, made numerous observations in proof of its being a disease of low and moist regions. In the chief village of the valley La Roja, which is situ- ated on high ground, there is not a goitre to be seen, though it is very prevalent in the immediate neighbourhood, which is comparatively low. He found, indeed, that all elevated regions, and all dry situations, whether warm or cold, were exempt from the disease; and he conceives that, throughout all climates, it takes its rise from the same cause —the humidity of the valleys. Dr. [Sir James] Clark, in his " Notes on Climate, Diseases, &c. in France, Italy, and Switzerland," states that he agrees in most respects with Fodere as to the origin of goitre, and expresses his opinion, that it is probable, if the villages situate in the low, close, marshy situations of the Vallais, were de- stroyed, and the inhabitants removed to elevated, dry situations, cretinism and goitre, which he be- lieves to arise from different degrees of the same cause, would disappear. Dr. Gibson, also, in the first number of the Philadelphia Journal for the Me- dical and Physical Sciences, has collected a great number of facts leading to the same conclusion. It appears from his statement, that bronchocele may be found as an endemic disease in all moun- tainous and marshy districts of the United States; that it generally prevails in valleys at the bottom of the highest mountains, in the neighbourhood of rivers, falls, lakes, or of the sea, and where the soil is rich and sheltered. Dr. James Johnson, in his Excursion through France, Switzerland, and Italy, recently published, has some excellent re- marks on the physical causes of bronchocele and cretinism in the valley of the Rhone, drawn from his own personal observation. « Were this valley beneath a tropical sun," says he, " it would be the seat of pestilence and death. As it is, the air must necessarily be bad; for the high ridges of mountains, which rise like walls on the north and south sides, prevent a free ventilation ; while in BRONCHOCELE. 347 Bummer a powerful sun beats down into the valley, rendering it a complete focus of heat, and extri- cating from vegetation and humidity a prodigious quantity of malaria. In winter, the high southern ridge shuts out the rays of a feeble sun, except for a few hours in the middle of the day; so that the atmosphere is not sufficiently agitated at any season of the year. To this must be added the badness of the waters, which, along the banks of the Upper Rhone are superlatively disgusting." In farther allusion to the same subject, he states that, " it is remarked that cretinism is bounded to certain altitudes above the level of the sea. The Vallais itself, and the ravines or gorges of the mountains by which it is enclosed, are the chief seats of this deformity. All, or almost all, those who inhabit the higher ranges of the mountains overlooking the valleys, are exempt from the ma- lady. This single fact proves that cretinism is owing to a physical rather than a moral cause, or series of cause-. There can be no material differ- ence in the moral habits of peasants residing at the base and on the brow of the same mountain. If the former be more subject to goitre and cre- tinism than the latter, it must be owing to some- thing in the air they breathe, the water they drink, or the emanations from the soil on which they reside. Saussure, Ferrus, Georget, and all those who have personal knowledge on the subject, acknowledge that at a certain height (five or six hundred toises) among the Alps, goitre and cre- tinism disappear." " In short, we find in the Vallais, and in the lower gorges or ravines that open on its sides, both cretinism and bronchocele in the most intense degrees; as we ascend the neighbouring mountains, cretinism disappears, and goitre only is observed; and when we get to a certain altitude, both maladies vanish." (pp. 56 to 58.) We believe that careful observation of the circumstances under which bronchocele is found to prevail in certain districts of our own country would lead to similar views respecting its origin; and in this manner may be explained the fact that with us it almost exclusively affects the lower orders, who are of necessity the most ex- posed to such causes, and to those concurrent cir- cumstances which poverty and ignorance entail upon them. Dr. Reeve, who visited the Vallais in 1805, for the purpose of making personal ob- servations on the causes of goitre and cretinism, remarks that " all the cretins he saw were in ad- joining houses in the little village called La Batia, situated in a narrow corner of the valley : the houses being built up under ledges of the rocks, and all of them very filthy, very close, very hot, and miserable habitations. In villages situated higher up the mountains, no cretins are to be seen." (Edin. Med. and Surg. Journ. vol. v. p. 33.) It would be wrong, however, to pass over the observations of the celebrated Humboldt, which certainly tend to throw some doubt upon these views. He observes that, in South America, bronchocele is met with both in the upper and the lower course of the Magdalen river, and on the flat high country of Bogota, 6000 feet above the bed of the river. The first of these regions is a thick forest while the second and third present a soil destitute of vegetation. The first and third are exceedingly damp, the second peculiarly dry. In the first the air is stagnant, in the second and third the winds are impetuous. In the two first the thermometer keeps up all the year between 22° and 23° of the centigrade scale; in the third it ranges between 4° and 17°. The waters drunk by the inhabitants of Mariguita, where goitres are the most hideous, are not those of snow, but of springs which flow over granite. He states, also, that the disease is progressively extending itself from the lower provinces to the flat elevated re- gions of the Cordilleras. (Journ. de Physiologie, par F. Magendie, t iii. p. 116.) Ramond, likewise, in his observations on the Pyrenees, informs us that cretinism and goitre exist amontr, these mountains even in greater ex- tent and degree than in the Vallais, and under circumstances of locality very different; namely, in open, well-watered, and well-ventilated valleys. Upon the whole, therefore, we are scarcely war- ranted by facts in considering that bronchocele has its origin in any one exclusive source; though, as we have already stated, we think it probable that most frequently it is the offspring of a close, stagnant atmosphere, impregnated with moisture and the effluvia of the subjacent soil. [There is something, at present, inscrutable in the character of the locality which gives occasion to the disease; and in reality we seem to know no more of the immediate cause of this endemic than of that of endemic diseases in general. (See the writer's Practice of Medicine, 2d edit. i. 557: Philad. 1844.)] As bronchocele arises without our being able to trace with certainty its cause, so does it often un- expectedly disappear without any assignable rea- son, even after resisting all the approved remedies. This has frequently occurred under a change of residence, a circumstance which favours the view that we have considered the most probable re- specting the origin of the disease. Alibert states that he has known many ladies in whom the tumour has subsided after a residence of some time in Paris. (Nosologie Naturelle, t i. p. 473.) Treatment.—A variety of means have been employed for its cure, both of a local and general nature. The former used to consist of dry rub- bing the part; bathing it with cold water; friction with stimulating lotions, liniments, or ointments; mercurial applications, leeches, and blisters, kept open or repeated. Electricity also has been em- ployed, and latterly galvanism, it is said, with some success. Of the internal remedies, till within these few years, the most celebrated was burnt sponge. This was generally exhibited in doses of ten grains to half a drachm, three times a day, in the form of an electuary, infused in wine, or made into a lozenge, which was kept under the tongue till dis- solved, from an idea that, in this manner, its in- fluence was more direct and speedy- It was usual, however, to accompany this remedy with altera- tive medicines and purgatives, chiefly mercurial; and although we believe the efficacy of burnt sponge, when unadulterated,* to be undeniable, it * It is stated by Dr. W. Gairdner, that chemists are in the habit of substituting charcoal for burnt sponge, of which an undeniable proof is the fact, that it is sold at a less price than unburnt sponge can be bought for. In this manner Dr. Gairdner explains the inefficacy of this medicine in the hands of British practitioners, whilst its 348 BRONCHOCELE. might not perhaps be easy to assign ite exact share as a remedy when combined with others. That mercurial preparations, internally administered, have in some cases cured the disease, even when burnt sponge has failed, there can be little doubt. There is an instance related by Mr. Davies, of Arelsford, in the 13th vol. of the Medical and Physical Journal, in which two pounds of sponge had been taken without any effect, and yet the tumour entirely disappeared in the course of ten days, while the patient was taking mercury inter- nally for some other ailment. Preparations of soda, potass, and iron; the muriates of barytes and lime ; egg-shells, burnt hartshorn, and even burnt toads, have likewise been recommended. Courses of sea-water, or mineral springs, and the use of distilled water, which has appeared to Pro- fessor Odier, of Geneva, (who ascribes the disease to the qualities of the water,) to prevent the in- crease of the swelling, and even to lessen its bulk, have also been advised. Of all the medicines, however, which have been administered for bronchocele, the substance called iodine is unquestionably the most efficacious, though it may not deserve the name of a specific, which some of its advocates have been inclined to claim for it. Of one hundred and twenty cases, treated by Dr. Manson, of Nottingham, where the disease appears to be endemic, seventy-nine were cured, eleven greatly relieved, and only two de- rived no relief. (Medical Researches on the Effects of Iodine.) It is now considered certain, that on the presence of iodine in burnt sponge depend the virtues of the latter in the cure of goitre. The discovery of this fact is disputed between Dr. Coindet of Geneva, and his countryman, Dr. Straub of Hofwyl. There is no reason, however, to suspect that either was aware of the other's researches while prosecuting his own. Dr. Straub appears to have been led principally by the simi- larity of smell between iodine, burnt sponge, and other marine productions, to suspect the existence of the former in these substances. Dr. Coindet whilst making researches for other purposes, found that the fucus vesiculvsus, or bladder-wrack, had been recommended by Russell for the cure of goi- tre ; and as it is from this plant, and other species of the same family, that the soda, with which iodine is generally found combined, is extracted, he was led to suspect that the virtues of sponge, likewise a marine production, might depend upon the same active principle ; a conjecture which was soon after continued by the discovery made by Dr. Fyfe, of Edinburgh, that iodine existed in the allies of burnt sponge. M. Roulin has found, likewise, that the aceyte de sal, a South American remedy for the disease, contains iodine. (Magen- die's Journ. de Physiologic, t. v. p. 273.) In whatever manner the question of originality may be decided, it must be admitted that to Dr. Coin- det's exertions we arc principally indebted for the speedy and extensive adoption of this new medi- cine. In goitre its effects may be obtained either by local application to the tumour, or by adminis- tering it internally. Where the former is suifi- virtues are so palpable and evident at Geneva that not only physicians, but also the inhabitants in general, are convinced of their reality.—Essay on the Effects of Io- dine, p. 2, 8vo. London, 1621. cient, it is preferable to the latter. The formula recommended by Coindet, and by Professor Brera of Padua, is that of an ointment, composed of half a drachm of hydriodate of potass mixed with an ounce and a half of lard, of which a drachm should be rubbed in over the surface of the swell- ing, morning and night. Brera, also, uses an ointment consisting of a drachm of pure iodine and an ounce of lard. Of this, the quantity to be rubbed in is a scruple at a time. Dr. Manson uses a liniment, composed of a drachm of the tincture of iodine mixed with an ounce of the liniment, sapon. comp., which may be kept in a phial, and the evaporation of the iodine, that takes place in the ointment, be thus, he says, prevented. For internal administration, the preparation in most common use in this country is the tincture. Coindet directs this to be made, by dissolving forty-eight Genevese grains of iodine (forty grains troy weight) in one ounce of alcohol. As, how- ever, the strength of the spirit varies, and it is liable to evaporate, a weaker tincture is preferable, from which the iodine is less likely to be depo- sited, and thus the deleterious action on the bow- els, which has appeared to Dr. Gairdner to be more marked in proportion to the free iodine in the preparation, avoided. Dr. Manson directs the tincture to be made in the proportion of twenty- four grains of iodine to an ounce of rectified spirit; and the dose of this may be from fifteen to thirty drops, three times a-day, taken in some distilled water. The dose of Coindet's tincture is from ten to twenty drops ; but Dr. Gairdner, who has had considerable experience in the use of iodine, and has given us an excellent description of its occa- sional mischievous effects, conceives this to be the most objectionable form in which it is used; and in this Dr. Kolley of Breslau seems to agree with him. (Reflexions, &c. sur l'emploie de 1'iode. Journ. Comp. Fevrier, 1824.) Iodine may also be given in the form of pills, containing each half a grain, made, as Brera directs, with elder- rob and liquorice-root Dr. Gairdner prefers the solution of the hydriodate of potass to any other preparations, for internal use. He directs it to be made by dissolving half a drachm of the hydrio- date in one ounce of distilled water; the dose is from ten to twenty drops. Dr. Manson prepares I it with twenty-four grains only to an ounce— Coindet with thirty-six. By adding ten grains of | iodine to this last, the solution of ioduretted hy- driodate of potass is formed, which Coindet con- siders the safest preparation for internal use. The dose of this should not exceed live drops, three times a day, on its first exhibition. There is an alcoholic, or ethereal tincture also, used by Coin- j det, which, next to the last, he prefers. Dr. Gaird. ner states that he has seen reason to believe that i bleeding from the arm in plethoric patients accele- rates the effects of the medicine, when absorption is slow. Goitrous tumours arc subject te sudden augmentation of ?ize during catarrh, or in febrile states of the body, and tha efficacy of the local application of iodine seems to be increased in such circumstances by a preliminary application of leeches. Dr. Coster relates a case in the Archives Generates de Medecine, for.July 1S23, in which galvanism and friction with iodine completely re- , moved a bronchocele, although neither of them BRONCHOCELE. 349 was successful by itself. And there can be no doubt that, when required, it is necessary to improve the general health, in order to afford the remedy a fair chance of success. When iodine is administered internally, it is necessary to avoid combining it with substances which may decompose it; it should be taken when the stomach is empty, and its effects carefully watched, as it has sometimes produced the most serious and even fatal consequences; though, under proper caution, it may be given with per- fect safety. Dr. Kolley, who was himself cured of goitre by means of iodine, after all other reme- dies had failed, and who has both taken and pre- scribed it largely, gives us some instructions with respect to the circumstances which have appeared to him to contra-indicate its use. He states that it is improper when there is a disposition to con- gestion in the head or other internal parts ; when febrile or inflammatory symptoms are present; in cases where there is diarrhoea, dyspepsia, or other gastric affection, or hepatic disorder ; when there is a disposition to hydrocephalus ; and in phthisis pulmonalis, for which it has been extolled as a remedy by some others. (Op. cit. — or Medico- (/hirurg. Review, Vol. vi. p. 229.) Dr. Gairdner informs us, that so great had been the ravage committed by the imprudent use of this medicine in the Pays de Vaud, that the government of that canton issued an injunction against its sale, ex- cepting under the signature and responsibility of a physician. The mischievous effects which follow its use are generally insidious in their approach. The patient becomes affected with a sense of faint- ness, tremor, and sinking ; dimness of vision, pal- pitation, and other symptoms of a nervous kind. The degree of tremor, Dr. Gairdner informs us, is sometimes so great, as to present some resemblance to chorea, though the limbs can always be kept steady, when not called on for exertion. More violent effects than these occur at times; symp- toms apparently proceeding from the direct and acrid effects of iodine on the alimentary canal, and strongly resembling the Indian cholera : — violent and incessant vomiting, strong spasms of the back and legs, extremely frequent, small, and oppressed pulse, urgent thirst, and excruciating pain of the stomach and bowels ; the latter being sometimes violently purged, at other times obstinately con- fined. For the prevention of all bad effects from the use of iodine, it is an excellent rule to begin with small doses, and increase them gradually, so as never to exceed the minimum quantity required. (Dr. E. Barlovj. Edin. Med. and Surg. Journ. Vol. xxi. p. 337.) The muscular spasms and the disturbance of the nervous system appear to be more benefited by attention to diet, air, and exer- cise, than by medicines. Of the latter, all that is required are mild aperient medicines, which, com- bined with gentle exercise in the open air, a mild, sparing, and nutritious diet, abstinence from wine and other stimulants, and the use of the warm bath, soon restore the patient to health. In the choleric affection, the remedies of much the great- est use are opiates, henbane, or hemlock, together with the warm bath, and mucilaginous drinks. Purgatives and bitters are decidedly injurious. In the second stage, when there appears to be an actual ulceration of the mucous membrane of the 2e bowels, the pulse, instead of being small and oscillating, becoming firm and bounding, the treatment requires much more discrimination. The diarrhoea, which assumes a dysenteric form, is best treated by the union of opium and ape- rients. The emaciation which follows the im- proper use of iodine is rapid and extreme. On some parts of the continent, a wasting of the mamma has occasionally been observed, during its use, even when cautiously administered ; and we have ourselves witnessed this effect. Dr. Manson found it, in one case, to excite ptyalism. The external use of the remedy seldom produces any unpleasant effects on the general system ; but it sometimes stimulates the arterial vessels of the tumour so powerfully as to produce pain and inflammation. In such cases, it may occasionally be necessary to bleed the patient from the arm, lest the inflammation should extend to the trachea; but, in general, the discontinuance of the medicine, together with fomentations, poultices, and leeches, is all that is required. [The preparations of bromine, as well as bromine itself, (see the writer's New Remedies, 4th edit: Philad. 1843,) appear to be equally efficacious in the treatment of goitre ; but they are not as much employed.] When both external and internal remedies fail in discussing the tumour, surgical measures have been adopted to destroy or remove it. Of the former, the application of caustics, as recommended by Celsus, is the oldest. This, however, is a dangerous as well as a painful and tedious mode of cure. Hemorrhagy, all but fatal, has sometimes occurred from it; and Dr. A. T. Thomson relates an interesting case, in the eleventh volume of the Medico-Chirurgical Transactions, in which, from empirical application of quicklime to an enormous goitre, the most dreadful inflammation, delirium, and sloughing ensued. The tumour has some- times been punctured with a trochar when it con- tained cysts, or cut into with the scalpel. The latter, it appears, is a very common practice in Denmark ; but unless a drain be in this manner instituted in the part, no very permanent benefit can be expected from it; and when suppuration does ensue, dangerous and even fatal symptoms have occurred from the formation of sinuses and sloughing. (Flujani, Colezzione d'Osservationi, &c. t. iii. p. 283.) Issues, also, have been estab- lished in the part, sometimes with success. Their operation apparently consists in breaking down the tumour by the suppurative process, but they may also act by communicating a stimulus to the absorbents. Goitres have been cured by sponta- neous suppuration, or by the inflammation and suppuration arising from accidental blows or wounds. It is reasonable enough, therefore, to expect that similar processes artificially excited should be followed by like good effects. When circumstances have rendered such means advis- able, the introduction of one or more setons in the tumour is the most effectual mode of accom- plishing it, and attended with the least risk of forming sinuses. Several writers of the last cen- tury recommended this mode of treatment for goitre, but the attention of practitioners in this country has been principally attracted to it by the Memoir of Dr. Quadri, of Naples, published 350 BRONCHOCELE. in the 10th volume of the Medico-Chirurgical Transactions ; and the operation has since been frequently performed in England. Some cases are published in the 11th volume of the Medico- Chirurgical Transactions, and in the 90th number of the London Medical Repository; from which it will appear that the operation is not so uni- formly successful and free from danger as Dr. Quadri found it to be. Alibert mentions a case in which a seton produced a partial diminution of the swelling ; but two years after it was with- drawn, the tumour became painful, suppurated, fifteen pints of matter were discharged, and six ounces daily for three months after ; yet, not- withstanding, the disease was only partially re- moved. (Nosologic Naturelle, t. i. p. 466.) That the success or failure of this remedy is in some measure dependent upon the nature of the swell- in? is extremely probable, but from what specific difference in that respect the difference of effect may arise we are as yet entirely ignorant. Dr. Quadri states that lie has passed a seton sixteen times in as many different directions through the tumour without any untoward accident. In one instance, endeavouring to perforate it pretty deep- ly, an unusual quantity of blood flowed from the wound, perhaps more than an ounce; and the tumour seemed to swell, as if injected with blood; but the bleeding ceased spontaneously, and he states his conviction, that unless the needle were pushed deep enough almost to touch the scuti- form cartilage, the principal trunks of the thyroid arteries would not be injured. He states, also, that the consecutive inflammation is of trifling consequence. When we consider, however, that the blood-vessels of the tumours are frequently very much enlarged, there may, without doubt, be occasional risk of hemorrhagy. In two out of the four cases in the 11th volume of the Medico- Chirurgical Transactions, hemorrhage did occur, though not to an alarming extent; and Mr. Sa- muel Cooper states that fatal hemorrhages have sometimes followed the operation. (Good's Study of Medicine, vol. v. p. 322.—Note.) It must be admitted, also, that active inflammation excited so near to the trachea may often induce danger- ous consequences, especially when the tumour is attached to that part. In one of the cases related in the Medico-Chirurgical Transactions, a patient of Mr. Gunning's, in St. George's Hospital, the operation was followed by fatal sloughing, and there was some appearance of inflammation on the lining membrane of the trachea. In another case, related by Mr. James, of Exeter, which, however, was ultimately cured, there occurred ex- pectoration of purulent matter and lymph, a great degree of orthopnoea, suppressed voice, as in laryn- gitis, and threatening death, until the seton was removed. Dr. Hedenus, of Dresden, informs us that he has seen a patient die of tetanus after the operation. From our own experience, indeed, as well as that of others in this country, we should say that it ought only to be attempted when symptoms urgently demand it. We have, it is true, seen it at times produce but few unpleasant symptoms, though we have witnessed at other times serious consequences from it; so, also, we have seen both successful and unsuccessful cases with regard to the ultimate cure. Of the former, a case has been reported in the Medico-Chirur- gical Review, vol. vii. 1827, treated by Mr. Henry Lyford, of the Hants County Hospital. The tumour, which was of four or five years' growth, and easily moveable, but unusually hard, almost entirely disappeared in less than two months. Dr. Quadri states that it is expedient to retain the seton in the tumour for a considerable length of time, in order to keep up the suppuration, until a cure is accomplished, as well as to prevent the formation of sinuses. When the suppuration ceases, and the wounds are perfectly healed, he has observed the curative process to go on in some cases until the goitre is entirely dissipated. The skin which covered the swelling remains corrugated a short time after the cure, but soon resumes its natural appearance; and the cicatnees left by the seton in a few months present hardly any deformity. With the view of cutting off the supply of blood by which the tumour is fed, the thyroideal arteries have been tied, and the disease, in some instances, removed by thus destroying the balance between absorption and deposition. Dr. Quadri, indeed, suggests that the effect may have been obtained simply from the increase of absorption, occasioned by the irritation of the ligature, and from the inflammation and suppuration consequent upon the operation.—(Medico-Chirurg. Transact. vol. x. p. 26.) But we cannot conceive that such causes are sufficient to account for so dispropor- tioned an effect. The experiment, we believe, was first attempted by Sir William Blizzard, and he succeeded in reducing the size of the swelling one-third in the course of a week; but the liga- tures having then sloughed off, repeated bleedings took place from the arteries, hospital-gangrene ensued, and the patient was lost. From the cir- cumstances of the case, however, the same event was by no means to be necessarily expected from the operation. Accordingly, in 1814, Professor Walther of Landschut repeated the operation in a case of that particular species of bronchocele which he calls the aneurismal. The patient was a young man, in whom the respiration was much impeded by the swelling, and the upper thyroid arteries were large and pulsated strongly. The left thyroid artery being tied, on the third day after the part of the tumour on that side became less tense, and the throbbing soon ceased. It continued to diminish gradually, becoming at the same time harder, and, as it were, cartilaginous. No febrile symptoms followed the operation, and the wound was completely healed on the twenty-third day. At the end of a fortnight, the left side of the swelling having diminished one-third, the Professor tied the right superior thyroid artery, with a like freedom from any unpleasant consequences. The right portion of the tumour also began to dimin- ish ; but, though originally smaller than the left, it did not waste away so completely as the latter, which at last was only one-third of its original size. Two years after, the remains of the tumour produced no inconvenience.—(Neue Heilart des Kropfes, &c. 8vo. Sulbach, 1817.) Another operation of the same kind was performed by Walther in 1820, and with still more complete success. In this patient, also, the tumour was [ tense, hard towards its centre, and pulsated strong- BRONCHOCELE. 351 ly- The face was pale and tumefied, the respira- tion obstructed, and deglutition extremely impeded. On exposing the left superior thyroideal artery, it was found dilated so much as to surpass the dia- meter of a common quill. After it was tied, it became considerably contracted below the ligature, and ceased to pulsate. At the end of seven weeks the wound was entirely cicatrised ; deglutition and respiration were performed without any diffi- culty ; the tumefaction of the face had disappear- ed ; the left half of the tumour, originally much larger than the right, was reduced to its natural size; and the patient left the hospital cured___ (London Medical Repository. October, 1822.) The first apparently successful case of the opera- tion in this country that we are acquainted with, was that of Mr. H. Coates, of Salisbury, published in the 10th volume of the Medico-Chirurgical Transactions. The patient was a young woman, in whom the tumour was so large as to render respiration and deglutition extremely difficult, and causing a noise in breathing, which might be heard at a considerable distance. The superior thyroi- deal arteries were large and pulsated strongly. The left of these vessels was taken up. On the next day there was headach, and some swelling of the neck and side of the head; but these gave way to the abstraction of blood, and in three days all unpleasant symptoms vanished. The wound was completely healed on the fourteenth day. The patient's breathing was much improved, the size of the tumour being reduced nearly one-half; and in less than seven weeks from the operation she was discharged from the hospital quite well. In consequence, however, of an application we made to Mr. Coates for information as to the final result of the operation, we are authorized to state that, though the case proceeded extremely well for some time after the patient was discharged and lost sight of, yet the tumour subsequently, he un- derstands, enlarged, and in the end destroyed her by suffocation. Mr. Coates states that he has not repeated the operation in any other case, nor should he be disposed to do so from the result in this in- stance. Mr. W. J. Wickham, of Winchester, has furnished us with the following notes of a case, in which one of the thyroid arteries was tied, in the Hampshire County Hospital, the operation being followed in like manner by apparent success at first, and failure in the end. He says, " It was the largest bronchocele I ever witnessed, but of the exact measurement I have no memorandum. After the ligature of the artery, the swelling gra- dually diminished for about six weeks, after which it as gradually regained its former size. It seemed that the decrease of the tumour continued so long as the part of the gland, which had been supplied by the vessel, remained without nourishment; but as soon as the supply was restored by the anastomosing branches from the opposite superior and the two inferior thyroideal arteries, the swell- ing returned to its former dimensions. Such, I should conceive, would be the case, unless all the thyroideal arteries were obliterated, which it would be a very difficult task to accomplish, if not alto- gether impracticable, from the depth of the lower vessels. In this case, after the foregoing operation, I introduced a seton through the gland, which was succeeded, at first, by great tumefaction of the part and alarming difficulty of breathing, but pro- duced afterwards a slight diminution of the swell- ing. After a few weeks, however, it was neces- sary to withdraw the seton in consequence of its having occasioned great constitutional disturbance, and ultimately no benefit at all was derived from it. The result of the case, indeed, does not irive me much encouragement to attempt a repetition of either plan of treatment on another occasion." Mr. Samuel Cooper mentions, in his Surgical Dic- tionary, that Mr. [Sir B.] Brodic performed the operation in one case without producing any mate- rial diminution of the tumour. Mr. H. Earle, how- ever, has been more successful. He has published the result of a case, in which he tied both the superior thyroideal arteries, with great advantage, though not with the effect of completely dissipating the tumour. The patient was a girl of seventeen, in whom the gland was very painful, and so large as greatly to impede respiration and deglutition. Her general health was bad ; she suffered much from pain in the head and drowsiness, and com- plained of pain in her chest, and cough, with foul tongue, and rapid pulse. As the disease did not yield to the usual remedies, she was sent back into the country on account of her general health, but returned some months afterwards with the goitre increased, so as to produce extreme dyspnooa, and totally prevent her from swallowing solid food. The pulmonary affection continued; there was constant headach and drowsiness, and.the pulse was 120. As the disease still resisted medicine, and threatened fatal consequences, the operation was determined upon. The right superior thyroid artery was found to be enlarged to the size of the carotid. On tying it, there succeeded intense headach and increased drowsiness, which were subdued by a full bleeding from the arm, leeches to the temples, purgatives, and digitalis. In a few days the tumour was found to be diminished, re- spiration and deglutition were much less impeded, and the cough had nearly left her. Within a month she was sent home; the circumference of the swelling being diminished three inches and a half. A fortnight afterwards, the tumour remain- ing stationary, she returned, to have the artery on the left side tied. This was found of the size of the radial artery. No urgent symptoms followed from its being taken up; but the diminution of the tumour was not nearly so great or so rapid as after the former operation. In a month the patient finally left the hospital, with no impediment in swallowing or respiration, and free from cough, the tumour being much softer and smaller. Three months after the operation it was continuing slowly to decrease.—(Med. and Physic. Journ. vol. hi. p. 201, & seq.) From all that we yet know of this operation, we may conclude that it may be performed, perhaps in most cases, with safety ; but that it is advisable in all instances of bronchocele is much more than doubtful. It appears not to have been uniformly successful even in reducing the tumour; still less in the complete removal of it. When it is considered, indeed, how largely the thyroid gland is supplied with blood, having four considerable arteries assigned to it; and how soon the place of obliterated trunks is supplied by the collateral branches; the occasional failure of the operation is not surprising, and the permanency 352 BRONCHOCELE —BULLAE. of its benefit, even in apparently successful cases, may sometimes, as we have seen, be questionable. When the urgency of symptoms, however, de- mands it, and more particularly when the tumour is of a pulsating nature, a dexterous surgeon may probably adopt this with as much safety and pros- pect of success as any other surgical means of relief. In some instances the goitrous tumour has been removed, at once, by excision. This, however, will appear to be a most hazardous undertaking, when we consider the number and magnitude of the bloodvessels, and the important nerves adjacent to the tumour, with which it is generally involved ; the impossibility of using much pressure in such a situation for restraining hemorrhage; and the risk of wounding the trachea and oesophagus, to which the deceased mass is often adherent. Pos- sibly the removal of the tumour at an early stage of its progress might not be attended with very serious danger. Mr. J. Baillie Fraser tells us, he was informed in his tour through the Himala mountains, that goitre, which prevails in the val- leys there, was sometimes cured when early means were taken, and that these consisted in extirpation of the part by the knife. He adds that he saw some persons with the scars from the operation on their throats, and that, in these instances, the cure was complete. (Journal of a Tour through the Himala Mountains, p. 349. 4to. London, 1820.) In 1791, Dessault extirpated a tumour of the right portion of the thyroid gland, which was five inches in circumference, and proved to be similar in all respects to scirrhous glands, ex- cept that in the centre there was a cartilaginous nucleus. In this case there were no very untoward circumstances, and the patient was dismissed cured on the thirty-fourth day after the operation. (Des- sault's Parisian Chir. Journ. vol. ii.) The diffi- culties and danger, however, attending the opera- tion, when the tumour is large, of long standing, and has formed extensive adhesions, are very great. Mr. Gooch relates two cases in which he attempted this mode of cure. In the first he was compelled to desist, before the operation was half completed, in consequence of profuse hemorrhage, which no means were able to stop ; and the patient died in less than a week. The second had nearly ended fatally, also, from loss of blood, this dex- terous operator being completely foiled in his at- tempts to stop the hemorrhagy by ligatures. The patient's life was only saved by having a succes- sion of persons to keep up a constant pressure upon the bleeding vessels, by means of their fin- gers, or proper compresses, day and night, for nearly a week. (Gooch's Medical and Chirurgi- cal Observations, p. 136.) The operation has been fatal, also, apparently from injury to some of the important nerves in the vicinity of the dis- ease. A woman on whom Dupuytren operated, without losing more than a few ounces of blood, was seized with hurried respiration, sickness, cold- ness of skin, &c, and died soon after the excision. The operation, however, has accomplished a cure, in some instances even of the most aggravated description. Vogel and Theden performed it with success. Professor Graefe, of Berlin, succeeded in a case where the tumour was so large that he thought it advisable to perform the operation by instalments, cutting off one side of the gland first, and, after waiting till the wound was healed, re- moving the other. In the course of the operation he took up fifty arteries. (Lawrence's Lectures; Medical Gazette, vol. vi. p. 719.) But of all who have attempted excision in bronchocele, Dr. Hede- nus, of Dresden, has heen the most fortunate. It appears that he has performed it six times with success. In one instance the circumference of the tumour was fourteen inches. The operation lasted an hour and a half. Some hours after, there com- menced a considerable oozing of blood from all the wounded surface, which it required assiduous care to suppress. After the separation of the liga- tures, on the eighth day, there was a considerable hemorrhagy, and on the eighteenth day a more serious one occurred in consequence of a convul- sive cough. The patient lost two pounds of blood ; there was a deadly paleness over his whole body, dimness of sight, loss of speech and hearing, and extreme faintness. By judicious treatment however, his life was preserved, and he was, at last, dismissed cured. (Graefe's Journ. der Chir. B. ii. p. 237. Berlin, 1822; or Quarterly Journal of Foreign Medicine. No. 19, p. 317.) A case was published some years ago, in which Klein re- moved a very large bronchocele, but the patient died upon the operating table. (Journ. der Chir. B. i. p. 120.—Journ. of Foreign Medicine, vol. ii. p. 380.) In short, judging from the results of the operation, even in the hands of the most judicious and highly skilful surgeons, we may venture to state that it ought scarcely to be attempted when the tumour is of great magnitude, and adheres firmly to the neighbouring structures, and certain- ly, in no case, until all other means have failed. Dr. [Sir James] Clark states that Mr. Major in- formed him of a case in which the tumour was successfully removed by ligature. In another, in which Mr. Major himself adopted that plan, the patient was lost in consequence of hemorrhagy, from neglect of the attendant; or rather, he sank under the low fever which ensued from it. (Op. cit. p. 111.) It should be kept in mind by the practitioner, that the removal or sudden subsidence of a bron- chocele is sometimes followed by irregular action of the heart, or some other functional disturbance, Andrew Crawford. BRONCHORRHCEA. (SeeBronchitis, Chronic.) BULL/E, blains, an order of cutaneous dis- eases characterized by an eruption of large thin vesicles, containing a serous or sero-purulent fluid, and succeeded by yellowish or blackish scabs, sometimes by ulceratioi . Syn. \vKraiviltc, ipM/criSts, (Hippoc. et vet. Grec.) ; X\on) Robley Dunglison.] [CECUM, DISEASES OF THE. (See Con- stipation.)] CALCULI, (Chemical Composition [a\d Microscopic Appearance.)]—The term calculus is applied to any solid or unorganized concretions found in the human body. Such concretions have been found in almost all the mucous cavi- ties and canals; in the lachrymal passages ; in the mouth, for the tartar in the teeth is certainly of this nature; in the tonsils; in the salivary and pancreatic ducts; in the stomach ; in the intes- tines ; in the gall-bladder and biliary passages ; in the ramifications of the bronchi; between the pre- puce and glans ; in the ducts of the mamma; in the vesiculs seminales; in the ducts of the pros- tate gland, and in the urinary canals and bladder. Earthy concretions have also been found imbedded in the substance of the brain and other soft parts; within scrofulous abscesses ; in cancerous cavities, and in hydatid cysts. The deposition of this earthy matter seems to take place around foreign bodies introduced into the animal frame, as the effect of the irritation which they cause, and pro- bably as the means of rendering them less ob- noxious to the living textures. Thus where an extra-uterine foetus has been long retained, it is usually found more or less encrusted with earthy matter; and when musket-bullets or other pro- jectiles have remained in the human body, their surfaces become covered with a coating of what appears to be phosphate of lime. Even the vas- cular system is not free from calculous concre- tions ; and small indurated masses have been found within the cavities of veins, which have thence obtained the name of phlebolithes. Chemical Composition of Calculi. — Cal- culous concretions were noticed by the ancients, and named, obviously from a notion that they were of a stony nature, Ai&'a by the Greeks, and calculi by the Romans. Hippocrates describes the symptoms of calculus in the kidney and urinary bladder with his usual precision. Pliny enume- rates a great number of remedies for this dreadful disease, and Celsus describes a method of extract- ing calculi from the bladder, which Heister praises as excellent. But we look in vain into the writings of the ancients for any description of calculi, or any examination of their nature. The first person who attempted to speculate respecting them was Paracelsus, though it is some- what difficult to form an accurate idea of the no- tions which he entertained on the subject. He seems to have thought that the calculus separates from the liquids of the living body in the same way that tartar is deposited from wine upon the sides and bottom of the wine-cask. This seems to have been the reason that induced him to give the name of tartar to calculi. This tartar, which is apt to be generated in the living body, was in Paracelsus's opinion the origin of most diseases. It differed in its qualities according to the nature of the liquid from which it was generated. He gave it the name of tartar, because it burns the patient like hell-fire in severe diseases. It is de- posited when the archeus acts with too much im- petuosity and irregularity, and when it separates the nutritive principle with too much activity. Then the saline spirit unites with the earthy prin- ciple, which always exists in the liquids, but in the state of materia prima,- and this union occa- sions the formation of tartar or calculus. The subject of calculus was taken up by Van Helmont, in his treatise De Lithiasi, which con- stitutes perhaps the most important and valuable part of all his works. He subjected various urinary calculi to a chemical investigation, and showed that they differed entirely in their nature from the stony bodies which occur in the mineral kingdom; from which he drew, as a consequence, that they did not originate from matter contained in food or drink. Tartar, he observed, was deposited from wine, not as an earth, but as a crystallized salt; and in the same way the natural salt of urine is precipitated to give origin to a calculus. This precipitation may be imitated by mixing spirit of urine (solution of carbonate of ammonia) with rectified spirit of wine. A white precipitate im- mediately falls, to which he gave the name of ossa alba. This view of the subject, which was to a certain extent just, induced Van Helmont to lay aside the name tartar, which had been em- ployed by Paracelsus; and to avoid ambiguity, he employed the term dueleeh, to denote the state in which the spirit of urine is precipitated when it gives origin to calculous concretions. These views he endeavoured to confirm by an analysis of urine, which was as perfect as could be ex- pected when the experiments were made, and cer- tainly enabled him to approach much nearer the truth than any of his predecessors had done. No attempt (so far as we know) was made to determine the nature of calculi, or to discover CALCULI. 355 remedies capable of dissolving them in the blad- der without injuring that organ, till the publica- tion of the second volume of Hales' Vegetable Statics, in the year 1733. He exposed different calculi to a red heat in a gun-barrel, and found that they yielded a quantity of air amounting to above five hundred times their bulk — a greater quantity of air than most other animal or vegeta- ble substances could be made to yield. This was a decisive proof (if any had been wanting after the experiments of Van Helmont) that urinary calculi are quite different in their nature from the stony bodies belonging to the mineral kingdom. Dr. Hales made several attempts to discover a sol- vent of urinary calculi, but it is unnecessary to relate them as they were not attended with suc- cess. In the year 1743, Dr. Whytt published an essay to show that lime-water was a remedy for the stone. This essay first appeared in the Edin- burgh Medical Essays, and was reprinted with them in 1747, and finally published separately in 1752. Soon afterwards Dr. Alston published A Dissertation on Quicklime, in which he deduces from his experience that lime-water may have a tendency to prevent the formation of calculi; but that it is incapable of dissolving them when once formed. As neither of these gentlemen made any experiments on the calculi themselves, their observations contributed very little towards im- proving our knowledge of the nature of these concretions. The analysis of calculi by Slare contributed but little to explain their nature, (Phil. Trans, vol. xvi. 140.) Boyle had subjected them to distillation, and had obtained an oil and a great quantity of carbonate of ammonia. Such was the state of the chemical knowledge of calculi, when, in the year 1776, Scheele pub- lished a set of experiments upon urinary calculi in the Memoirs of the Stockholm Academy, (Un- tersokning om Blose Stenen, p. 327.) He found all the calculi that he examined of the same na- ture. He could discover in them no sulphuric acid and no lime ; but they consisted of a pecu- liar substance possessing acid properties," and cha- racterized by dissolving with effervescence in nitric acid, and assuming a beautiful pink colour when the solution is evaporated to dryness without the application of too much heat. To this acid the name lit hie acid was afterwards applied, which by Fourcroy was changed into uric acid, in con- sequence of a remaik of Dr. Pearson. Scheele showed that all urine contains this acid. Hence the origin of urinary calculi came to be under- stood. Whatever has a tendency to throw down uric acid from urine may give origin to a calculus. To this paper of Scheele an appendix was add- ed by Bergman, in which he stated the result of his own experiments. He detected the uric acid which Scheele had discovered, but found also some lime in all the calculi which he examined. This important paper of Scheele constituted the first step, and it was a material one, towards a full investigation of the nature of urinary calculi. Hardlv any addition was made to the facts as- certained by Scheele and Bergman till the year 1797, when Dr. Wollaston published a paper on gouty and urinary concretions, in the Philoso- phical Transactions. In this paper he gave an account of three species of urinary calculi, quite different in their composition from those described by Scheele. The concretions which appear in the joints of gouty persons, and which had been known to medical men by the name of chalk stones, he ascertained to be a combination of urit acid and soda. To the three new species of cal culi he gave the names of fusible calculus, mul- berry calculus, and bone-earth calculus. The fusible calculi had been first noticed by Mr. Smithson Tennant, who found, that when urged by the blow-pipe, instead of being nearly consumed, as happens to the uric acid calculi of Scheele and Bergman, they left a large proportion which fused into an opaque glass. This he con- jectured to be phosphate of lime mixed with other phosphoric salts of urine. Dr. Wollaston found that this kind of calculus was white, and that it consisted partly of sparkling crystala composed of ammonia-phosphate of magnesia. These crys- tals had the form of short triangular prisms, hav- ing one angle a right one and the other two equal, and terminated by a pyramid of three or six sides. The other constituents of this calculus are phos- phate of lime, and a very small quantity of uric acid. The mulberry calculus had been noticed and named before by medical men ; but no attempt had been made to determine its nature. The sur- face is irregular and knotted, bearing a distant resemblance to the mulberry. Dr. Wollaston showed that it is composed of oxalate of lime, mixed with a little blood and other animal matter. Calculi of the same nature are sometimes met with, smooth on the surface, and much lighter coloured. These, from their appearance, were called hemp-seed calculi, and were not suspected to be of the same nature with the mulberry, till Dr. Wollaston ascertained their composition. The bone-earth calculi are of a brown colour, and so smooth as to appear polished; they con- sist of regular lamins, easily separated from each other. Dr. Wollaston showed that they are coin- posed of phosphate of lime : hence the name by which he distinguished them. Before the blow- pipe this calculus is slightly charred: it then be- comes white; and when urged with the utmost heat from a common blow-pipe, it is at length fused. As this cannot be done with the earth of bones, Dr. Wollaston infers that the bone-earth calculi are composed of neutral phosphate of lime ; whereas the earth of bones is known to be a sub- sesqui-phosphate of lime, or a compound of— 1 atom phosphoric acid.........4.5 1 £ atom lime.................5.26 ~9.T5 Dr. Wollaston, in this important paper, also examined the calculi from the prostate gland, and found them composed of neutral phosphate of lime tinged with the secretion of the prostate gland. Some years after, a set of experiments on uri- nary calculi was published by Fourcroy and Vau- quelin. They examined no fewer than five hun- dred different calculi, and were thus enabled to add a little to the important discoveries of Dr. Wollaston, to which, however, they make no al- 356 CALCULI —[BILIARY.] lusion in their paper. They found calculi com- posed of urate of ammonia; and in two different calculi they found a small quantity of silica. The animal matter which serves as a cement to the constituents of the calculus, they consider as sometimes consisting of albumen, and sometimes of urea; but it is evident from the way they speak of it that they had not subjected it to a rigid examination. The next addition to the chemical knowledge of the nature of calculi was made by Dr. Wollas- ton in 1810, (On a new species of Urinary Cal- culus, Phil. Trans. 1810, p. 223); by the dis- covery of a urinary calculus composed entirely of a peculiar substance capable of combining equally with acids and alkalies, and which he dis- tinguished by the name of cystic oxide. It is of rare occurrence ; only about six or seven such calculi having been hitherto met with. The labours of Austen, Walther, Brugnatelli, Pearson, Brande, &c, have not added many new facts to those already known; but Dr. Marcet, in his Essay on the Chemical History and Medical Treatment of Calculous Disorders, published in 1817, gives an account of two new species of calculi which he had observed. The first, which he received from Dr. Babington, weighed eight grains, and was composed of a substance to which Dr. Marcet gave the name of xanthic oxide, from the lemon yellow colour which it forms when act- ed upon by nitric acid. The other calculus was about the size of a pea, and the substance of which it was composed possessed the characters of fibrin. On that account Dr. Marcet gave it the name of fibrinous calculus. In the year 1821, Dr. Prout published An In- quiry into the Nature and Treatment of Gravel, Calculus, and other Diseases connected, with a deranged Operation of the Urinary Organs ; a new and improved edition of which appeared in the year 1825. In this work he treats at large on urinary calculi, and the states of the urine connected with their formation; and has thrown more light upon the subject than any preceding writer. Such is a short history of the principal discove- ries respecting calculi, chiefly of the urinary or- gans We shall now take a view of the differ- ent calculi which are apt to form in living ani- mals, and point out their nature, and the causes of their formation, so far as the subject has been investigated. The calculi formed in living bodies are distin- guished according to the organs in which they appear. We shall notice them in alphabetical order, dwelling principally on their chemical com- position. 1. Biliary calculi, formed in the gall-bladder. 2. Gouty concretions, formed in the joints of gouty individuals. 3. Intestinal concretions, formed in the sto- mach and intestinal canal of man and the inferior animals. 4. Ossifications or concretions which occasion- ally form in the pineal gland, the salivary glands, the pancreas, the liver, the spleen, the lungs, &c. 5. Calculi formed in the prostate gland. 6. Urinary calculi, formed in the kidney or ttrinary bladder. I. Biliary Calculi.—Hard bodies occasion- ally form in the gall-bladder, which, making their way into the duct through which the bile passes into the intestinal canal, prevent the bile from passing, and thus occasion the well-known dis- ease called jaundice. These concretions have received the name of biliary calculi, or gall-stones. Though their existence was known to the an- cients, and though they had been imperfectly de- scribed by medical men, scarcely any thing was known respecting their nature till they were ex- amined by Poulletier de la Salle, about the year 1784, who found that they were partly dissolved by boiling alcohol, and that the alcohol on cool- ing deposited a number of brilliant white plates, bearing some resemblance to spermaceti. The subject was taken up by Fourcroy in 1785, who compared the matter of gall-stones to the fatty mat- ter into which human bodies had been converted when left in great numbers, piled on each other, to spontaneous decomposition. To this substance he gave the name of adipocire; and the same name was applied by him to the chief constituent of gall-stone. In 1814, Chevreul showed that these notions of Fourcroy were inaccurate; that the substance discovered by Poulletier de la Salle in gall-stones was quite different from Fourcroy's adipocire. Chevreul gave it the name of choles- terine (solid bile), and showed that it existed as a constituent in bile. The biliary calculi hitherto described may be divided into three species, name- ly, cholesterine calculi, mellitic calculi, and calculi composed of inspissated bile. 1. Cholesterine Calculi.—These calculi are not by any means so abundant as those belong- ing to the second species, if we are to judge from the number which we have ourselves seen. They have a white colour, and a crystallized, shining, lamellated structure. Pretty frequently they have a slight shade of brown, sometimes indeed a de- cided brown colour, owing doubtless to the mat- ter of bile interspersed through them, but in too small quantity to be visible to the eye, except by affecting the colour of the calculus. These cal- culi are composed of cholesterine, nearly in a state of purity. The largest we have seen was about the size of a hazel-nut, and very nearly spherical. It is exceedingly light, owing to the low specific gravity of cholesterine. Cholesterine, when pure, has a white colour, and a silky or pearly lustre. It is lighter than water; it is tasteless and insoluble in water, and possesses little or no smell. Boiling alcohol dis- solves about the fifth part of the weight of it, but deposits it on cooling in small brilliant plates. When heated to about 279° it melts, and in a vacuum it may be sublimed without decompo- sition. It does not combine with potash, nor can it be converted into a soap. According to the analysis of Chevreul, it is composed of— 1 atom oxygen............ 1 37-5 atoms carbon.......... 28-125 31-5 atoms hydrogen........ 3-9375 "33^0625 But as it possesses neither acid nor alkaline cha- racters, and is not known to combine in definite proportions with other bodies, we have no means CALCULI —[GOUTY AND INTESTINAL.] 357 of determining whether these numbers or some multiple of them constitute the true compositions of it. 2. Mcllltic Calculi. — We have given this name to by far the most common species of biliary calculi; and we have named them from the colour, which bears a considerable resemblance to honey, only it is browner. These calculi have always a polygonal shape, occasioned by mutual pressure; for a number of them always exist in the gall- bladder together. We have taken six out of a gall-bladder after death, and the gall-bladder in that case was almost filled. Most commonly they have three blunt edges, and have some resem- blance to two low tetrahedrons applied base to base, with their edges and angles rounded off. The mean specific gravity is about 1-061. Their outer surface is smooth, and has a soft feel. When broken, they exhibit a thin outer crust, composed of concentric layers crystallized in small rays in- clining towards the centre. These crystals consist of cholesterine. The nucleus has usually the appearance of granulated honey, and consists of inspissated bile. In the calculi of this species, which we have subjected to analysis, very nearly 19.20ths of the whole was cholesterine. The rest was a mixture of picromel and some other animal matter, which was too small in quantity to admit of a rigid ex- amination. 3. Inspissated Bile Calculi.—This species has a yellow colour, contains little or no choleste- rine, but is entirely composed of inspissated bile. So far as our observations go, it is much more uncommon than either of the other two. That it exists, however, there can be no doubt, as Thenard examined several biliary calculi belonging to this species. The gall-stones of oxen are usually of a yellow colour, and consist of the yellow matter of bile mixed with minute traces of bile, which may be separated by water. When thus washed, they are tasteless and insoluble in water and in alcohol. They are used by painters, though their colour is not permanent but soon changes to a brown. As all the constituents of biliary calculi exist in the bile, there is no difficulty in understanding how they may be deposited when the proportion of the constituents of that liquid undergoes altera- tion. Cholesterine has been rarely found in biliary calculi of the inferior animals ; but that it exists in them also is certain; for Lassaigne found the constituents of a biliary calculus from a sow which he examined, as follows :— Cholesterine................ 6 White resin................. 44-95 Bile....................... 3-60 Animal matter............... 45-45 100.00" Ii. Goutt Calculi. — It is well known that ioncretions occasionally make their appearance in joints long subject to gout. These concretions, from their colour and softness, have received the name of chalk-stone. They are usually small, though they have been observed of the size of an egg. Their nature was first discovered by Dr. * Ann. 0e Chim. et de Phys. 31,220. Wollaston in 1797, who proved that they were combinations of uric acid and soda, or composed of urate of soda. Gouty concretions are soft and friable. Cold water has little effect upon them ; but boiling water dissolves a small portion. If an acid be added to this solution, crystals of uric acid are deposited on the sides of the vessel. They are completely soluble in caustic potash when the action of the alkali is assisted by heat. When they are treated with dilute sulphuric or muriatic acids, the soda is separated, while the uric acid remains, and may be obtained in a pure state by filtration and washing. When the liquid is eva- porated, it yields crystals of sulphate of soda or of common 6alt, according to the acid used. When the uric acid thus obtained is distilled, it yields ammonia, prussic acid, and the acid subli- mate of Scheele (pyruric acid). When dissolved in a little nitric acid, it tinges the skin of a rose colour, and, when evaporated, leaves a rose- coloured deliquescent residuum. III. Intestinal Calculi.— Concretions of very considerable size are sometimes found lodged in the stomach and intestines; not so frequently in the human body, but very often in some of the inferior animals. The only intestinal concretions from the human body which we have seen are in the collection of the late Dr. Monro, of Edinburgh, and may still be seen among the preparations belonging to the anatomical class in the University of Edinburgh. They amount to forty-one, and are all very nearly of the same nature, though they differ in size. There are fifteen calculi exactly similar in the collection of calculi made by Dr. Hunter, and now belonging to the University of Glasgow. The largest of these weighs 1057 grains, and as some parts of it are wanting, there can be little doubt that its weight, when entire, was at least 1100 grains. These calculi have a brown colour, and are composed of fibres interwoven together after the manner of felt. They have altogether a cer- tain resemblance to sponge. They feel soft, but are too hard to be much compressed. The specific gravity is about 1-4. One of those in Dr. Hun- ter's collection has a fruit-stone for a nucleus. In most of those in Dr. Monro's collection no nucleus whatever can be observed. Dr. Monro used to mention, in his lectures, that these concretions had been found in the colon, and that they had all proved fatal. The principal constituent in these concretions is the felted fibrous matter, which was naturally supposed to have been derived from the food. Mr. Clift, of the College of Surgeons, London, conjectured that it might proceed from oats. This induced Dr. Wollaston to examine the structure of the oat-seed, and the result fully verified Mr. Cliffs conjecture. If the oat-seed be denuded of its husk, minute needles, or beards, forming a small brush, are seen planted at one of ite ends. Dr. Wollaston, on examining these needles, and comparing them with similar ones detached from the calculi, satisfied himself of their perfect identity. Hence these concretions were owing to the use of oats as an article of food: as oats are employed by the common people of Scotland as a common article of food, we see a reason why these concretions have been observed 359 CALCULI —[OF THE PROSTATE.] chiefly in Scotland. Mr. Children gives an account of some formed in the human intestines, in Lan- cashire, where also oat-meal is in constant use by the common people. (Phil. Trans. 1822, p. 24.) The other constituents of these calculi are albu- men, common salt, phosphate of lime, and phos- phate of soda. These are not the only calculi which have been found in the human intestines. Mr. E. Brande described some composed entirely of carbonate of magnesia, resulting from an excessive and con- tinued use of magnesia for a long time. In one case a collection of several pounds of this sub- stance was found lodged at the head of the colon, which in consequence was much distended. (Royal Institution Journal, i. 297.) Dr. Marcet describes intestinal calculi voided by the rectum possessing the properties of indurated curd or cheese. (Marcet on Calculous Disorders, p. 127.) He describes other small granular concretions, which were conjectured by Dr. Wollaston to be the small woody knots which are often found in certain pears; and upon close examination this conjecture was found correct. (Marcet on Calcu- lous Disorders, p. 132.) Some years ago the writer of this article re- ceived from an eminent physician in Birmingham a number of small flattened oval particles, which had been voided by a patient of his. They had all the appearance of seeds, but did not resemble any seed with which we were acquainted. At last, after carrying about the bodies for a conside- rable time and comparing them with the seeds of every species of fruit which he had an opportunity to inspect, we found that they were the seeds of figs. The patient had been eating green figs, the seeds of which had been voided entire. Mr. Children gives an account of a very re- markable intestinal calculus which destroyed the life of John Chambers, a young carpenter at Cli- thero in Lancashire, who had been in the habit of eating large quantities of unripe plums, and of swallowing them together with the stones. Three concretions were formed in the arch of the colon, having a plum-stone for a nucleus, which in a short time destroyed his life. These concretions, together with some others collected by Mr. Barlow and Mr. Coultate, surgeons in Lancashire, which are deposited in the Museum of the Royal Col- lege of Surgeons, London, appear, from Mr. Children's description, to be intermediate between the oaten concretions in the collection of Dr. Monro and Dr. Hunter, and the triple phosphates, which occur so frequently in the intestines of the inferior animals. They were laminated, and com- posed of alternate layers of the felted fibres of the oat and the triple phosphates. The following table exhibits the constituents of one of these concretions as determined by Mr. Children : Animal matter, chiefly gelatin...... 25-20 Resin.......................... 3-90 Ammonia-phosphate of magnesia.... 5.16 Phosphate of lime................ 45-34 Fibres of the oat................. 20-30 99-90* The calculi found in the intestines of the infe- * Phil. Trans. 1892, p. 28. rior animals were examined with much care by Fourcroy and Vauquelin many years ago. They describe the following varieties: 1. Diphosphate of Lime Calculi. — They are composed of concentric layers, and very brit- tle. They redden vegetable blues, and are partially soluble in water. 2. Phosphate ©fMagnesia Calculi.—These concretions are described as semi-transparent and of a yellowish colour. Their specific gravity is 2-160. They are laminated. They are doubtless very uncommon. We ourselves have never had an opportunity of seeing any of them. 3. Ammonia^phosphatc of Magnesia Cal" culi—said to be very common. Their colour is grey or brown, and they are composed of crystals diverging like rays from a centre. 4. Fungous Calculi.—These concretions are composed of pieces of the boletus igniarius, dis- posed in layers, and cemented by animal matters. These pieces had of course been swallowed by the animals in whose intestines they were found. 5. Hairy Calculi. — These are found in the stomach and intestines of cows and sheep. They consist of balls of hair felted together, and gene- rally coated externally with a very thin crust of animal matter. The hair had obviously been licked by the animals from their companions, and had been felted by the action of the stomach and intestines. There are several of these concretions in the collection of Dr. Hunter belonging to the University of Glasgow. The same collection contains enormous calculi composed almost en- tirely of phosphate of lime; but as there is no history attached to them, we have not ventured to describe them, because we do not know from what animal, or from what part of the animal, they were obtained. 6. In the same collection are five or six of the celebrated oriental bezoars, once so much sought after as medicines of approved efficacy. They are all smooth and polished, and have a greenish colour. They are small and round, and long, so as to have a considerable resemblance to a cylin- der rounded off at the ends. Three of these bezoars, sent by the Schah of Persia to Bonaparte, were found by Berthollet to be composed of frag- ments of wood. Another kind of these bezoars (probably artificial), analysed by Fourcroy and Vauquelin, was found composed chiefly of resin. IV. Ossifications. — Concretions are apt to appear in various glands of the living body. These consist constantly of phosphate of lime and animal matter; or of a mixture of phosphate and car- bonate of lime and animal matter. In some rare instances they consist almost exclusively of car- bonate of lime and animal matter. The seats of these ossifications, as they may be called, are the pineal gland, the salivary glands, the pancreas, the lungs, the liver, and the spleen. The concre- tions coughed up from the lungs usually contain some carbonate of lime, and in some rare cases seem to be nearly destitute of phosphate of lime. V. Calculi of the prostate gland.— [Prostatal Calculi.—Prout] Calculi occasion- ally form in the prostate gland, sometimes in great numbers at a time and of small size, but occasion- ally in smaller numbers, and of a size nearly as large as that of a hazel-nut Often they do not CALCULI —[URINARY.] 359 exceed the size of the head of an ordinary sized pin, and they are rarely larger, judging from those which we have seen, than a pea. These calculi were first examined by Dr. Wollaston, who found them composed of phosphate of lime, mixed with more or less animal matter. Dr. Prout informs us that he has met with calculi from the prostate gland containing a considerable proportion of carbonate of lime. The writer of this article has met with five or six which contained very little earthy matter, but which were composed chiefly of a substance having considerable analogy to cystic oxide. These calculi, when small, arc nearly spheri- cal, and have a yellowish brown colour : those of a large size are smooth and polished, and have the appearance of porcelain; precisely similar, indeed, to the phosphate of lime calculi formerly described. Dr. Prout is of opinion that these porcelainous calculi always originate in abscesses of the prostate gland. But there are not a few of them in Dr. Hunter's collection of such a size that they could not possibly have been deposited in any cyst of the prostate gland. These calculi sometimes give little uneasiness, and are not sus- pected till after death. [The composition of all calculi of the prostate, according to Dr. Prout, (On the Nature and Treatment of Stomach and Renal Diseases, Amer. edit, from the 4th revised Lond. edit p. 448, Philad. 1843,) is nearly the same,—that is, they consist chiefly of phosphate of lime, a little car- bonate of lime, and animal matter. In different instances, the relative proportions of the phos- phoric acid to the lime and the carbonate of lime appear to vary considerably.] Urinary calculi. — The constituents of urinary calculi, so far as we know at present, are the following substances :— 1. Uric acid. 2. Urate of ammonia. 3. Urate of soda. 4. Phosphate of lime. ' 5. Ammonia-phosphate of magnesia. 6. Carbonate of lime. 7. Silica ? 8. Cystic oxide. 9. Xanthic oxide. 10. Colouring matter of urine. 11. Purpurate of ammonia. 12. Fibrin. 13. Mucus. 11. Urea. These substances seldom appear insulated or constituting each a whole calculus. In general several of them appear together, either mixed or constituting alternate layers. To enable us to form correct notions respecting the way in which they make their appearance in the urinary organs, it will be requisite in the first place to make a few remarks upon urine. Urine, as is well known, is a liquid secreted from the blood by two large glands called the kidneys, possessing a remarkable structure which has been minutely described by anatomists. The quantity of urine voided daily differs very much in different individuals, depending in some mea- sure on the quantity of drink and upon the state of the skin. But perhaps two pounds avoirdupois or 14,000 grains approaches somewhat to the general average. It is transparent, has a light amber colour, and, when voided, has an aromatic odour, which has been compared to that of violets As it cools, this aromatic odour leaves it, and an other succeeds, well known under the name ol urinous. In two or three days this smell is sue I ceeded by another, which has a considerable re semblance to that of sour milk. It has a disagree-' able bitter taste, and a specific gravity which varies very much; but which may be stated as vibrating between 1-010 and 1-020; though in certain diseases it rises as high as 1-050, or sinks as low as 1-003. [According to F. D'Arcet (UExperience, No. Iv., Aug. 1838), it varies be- tween 1-001 and 1060. Dr. Thomson (British Annals of Medicine, p. 5, Jan. 1837) found its specific gravity in an individual from 50 to 60 years of age, and in perfect health, to bear the average 1-013; — the lowest specific gravity be- ing 1-004, and the highest 1-026 .- (see the writer's Human Physiology, 5th edit i, 294: Philad. 1814.)] It reddens vegetable blues, owing probably to the presence of a little urate of ammonia, and to some biphosphates which it always holds in solu- tion. If we add to healthy urine a few drops of any acid, and set it aside for some time, small red coloured crystals are deposited. These consist of uric acid tinged by some colouring matter. If we evaporate a quantity of healthy urine to one half its natural bulk, and then mix it with nitric acid, and set it aside in an open vessel, a number of beautiful crystals in plates make their ap- pearance. They have a light yellowish brown colour and a silky lustre, and consist of urea combined with nitric acid. The presence of sulphuric acid can be detected in urine by means of a solution of chloride of barium ; muriatic acid may be detected by nitrate of silver; and phosphoric acid by nitrate of lead ; the white precipitate thrown down by which, as far as it is a phosphate, being again dissolved by the addition of nitric acid. Lime may be detected by means of oxalate of ammonia. The quantity of magnesia in urine is so small that it is scarcely possible to detect its presence by re-agents. But if a quantity of healthy urine be left for two or three weeks in a cylindrical glass vessel, the mouth of which is covered with paper, and then be poured out, we shall find attached to the sides of the glass a number of small transparent crys- tals consisting of four-sided prisms with square bases. These crystals constitute a double salt composed of One atom phosphate of ammonia 6-625 One atom phosphate of magnesia 7 The formation of these crystals proves evidently that magnesia exists in urine, though only in minute quantity. Urine also contains potash, soda, and ammonia; the last of which may be detected by the smell, if we add caustic potash to urine concentrated by evaporation over sulphuric acid in the vacuum of an air-pump. If we con- tinue this evaporation nearly to dryness, crystals of sulphate of potash and sulphate of soda make their appearance in it, proving that both potash and soda enter into the constitution of urine. The following table exhibits the constituents of 360 CALCULI—[URINARY.] healthy urine according to Berzelius's analysis, which is the latest that we have. Water........................93-300 Urea......................... 3-010 Uric acid...................... 0-100 Mucus........................ 0-032 Lactic acid, lactate of ammonia, &c* 1-714 Sulphate of potash.............. 0-371 Sulphate of soda................ 0.316 Phosphate of soda............... 0-294 Phosphate of ammonia........... 0-165 Chloride of sodium............... 0-445 Sal-ammoniac.................. 0-150 Earthy phosphates, with a trace of fluorid of calcium............. 0-100 Silica......................... 0-003 100-000 Besides these substances, which form constant ingredients of healthy urine, this liquid in dif- ferent diseases has been found to contain albu- men, fibrin, and red globules of the blood ; nitric acid, purpuric acid, oxalic acid, carbonic acid, benzoic acid ; cystic oxide, sugar, bile, pus, and doubtless also xanthic oxide, though that has not yet been ascertained by observation. Of these different constituents of urine there are only two that it will be requisite to describe particularly in this place. These are urea and uric acid. Urea, when pure, is a transparent colourless 6ubstance, having a pearly lustre and crystallizing in four-sided prisms. Its taste is feeble; but it leaves a sensible coldness on the tongue like nitre. Its smell is slight, but peculiar, and quite dif- ferent from that of urine. When exposed to damp air it deliquesces, but does not seem to be decomposed. The specific gravity of its crystals, as determined by Dr. Prout, is 1-350. At 60° water dissolves more than its own weight of it, and the solution may be exposed to the air with- out undergoing any change, provided it be pure ; but if it be contaminated with the smallest quan- tity of foreign matter, it is speedily converted into carbonate of ammonia. Boiling water dissolves any quantity of it whatever. Alcohol of 0-816 dissolves at 60° about the fifth part of its weight of it, and at a boiling heat more than its own weight; but when the liquid cools, the excess of urea separates in crystals. When mixed with the caustic alkalis or alkaline earths, and heated (provided water be present), it is decomposed and converted chiefly into carbonate of ammonia. A number of curious facts, respecting the relation existing between urea and cyanogen have lately been discovered, which throw considerable light upon the occasional existence of prussic acid in urine,—a fact which seems pretty well established; but it would lead us too far from the subject of calculi to state them here. [By the aid of the microscope, the presence of a very minute proportion of urea may be ascer- tained. If its aqueous or alcoholic solution be evaporated, and then a little nitric or oxalic acid be added, delicate silky crystals of nitrate or oxalate of urea are perceptible. The evaporation *The writer of this article has in vain endeavoured to ascertain the presence of these bodies in urine. should be performed on a glass slide, and the subsequent crystallization be examined by the microscope. (Dr. Griffith, Practical Manual, &c, p. 17, Lond. 1843.)] Uric acid, when pure, is a white, tasteless sub- stance, existing either in powder or in nunute crystals, which seem to be four-sided prisms. It has no smell. According to Dr. Henry, it is soluble at 60° in 1720 parts of water; but Dr. Prout could not dissolve it in 10,000 times its weight of water.f It dissolves readily in a solu- tion of caustic potash or soda, from which it may again be precipitated in a white powder by the addition of almost any acid. It dissolves in nitric acid with effervescence, when assisted by heat When the solution is gently concentrated, crys- tals of erythric acid form in it. When the liquid is evaporated to dryness, a beautiful pink sedi- ment remains, which is a characteristic of this acid. On one occasion we have seen uric acid converted into urea by digestion in nitric acid. The experiment was made by a surgeon who wished to determine the nature of a calculus which he had extracted. The result not being satisfactory, he brought both the calculus and the substance into which he had converted it, to the writer of this article. The calculus was the com- mon uric acid calculus, mixed apparently with muriate of ammonia. The substance into which it had been converted was urea. The surgeon could not give a satisfactory account of the pro- cess which he had followed, and we attempted in vain to repeat it successfully. Uric acid combines with the different bases, and forms salts nearly insoluble. The urate of ammonia is the most soluble; it dissolves in about 480 times its weight of water, and the solu- tion has the property of reddening vegetable blues. If we put a quantity of healthy urine under the exhausted receiver of an air-pump over sulphuric acid, and allow it to evaporate spontane- ously, a sediment of urate of ammonia gradually attaches jtself to the sides of the vessel in which the urine is. This seems to prove that in urine the uric acid is in the state of urate of ammonia. [Uric or lithic acid is always crystalline. As occurring in urine, the crystals are always co- loured. Their varieties of form are endless; and they are either separate, or combined in clusters. When separate, the outlines are either rhomboidal, square or rectangular; and all their varieties, ac- cording to Dr. Griffith, (op. cit.,) are explicable by assuming them to be derived from the right rhombic prism. When examined by polarized light, the crystals of lithic acid develope splendid colours. Urate or lithate of ammonia is almost always amorphous. The radiating needles, seen upon its surface have been described as composed of super- lithate of ammonia; but Dr. Griffith states, that t The probability is that both of these statements (in- compatible as they may at first sight nppear; arc sub- stantial correct. Dr. Henry probably digested uric acid in water of responding with the choleric stage of the ordinary type, we had no opportunity of ascertaining whe- I ther any or what form of fever would ensue. 3. Prognosis.—The danger of the disease is in all cases, we believe, to be estimated from the degree of collapse attending the cold or choleric stage. In India, it was remarked that the cases in which the spasms and vomiting were the most violent were by no means fraught with the most peril, and what we have seen of the disease ena- bles us to bear testimony to the accuracy of the remark; for when we have heard attendants ex- ulting in the cessation of the spasms and the fa- cility with which the stomach retained medicine or food, and have felt at the same time the pulse- less wrist and the cold and clammy hand, we have seen in these apparently favourable omens only the natural progress of the disease from a bad condition to one still worse. Whether we are to dread a fatal result in the cold or the excited stage, the intensity and duration of the collapse in the former of these stages are the measure of the dan- ger ; for if the patient die in this stage, he dies of collapse, and if he survive it and pass into the state of fever, the character of this fever is malig- nant and dangerous i:i proportion to the same col- lapse. 4. Diagnosis.—.'From ordinary cholera the cold stage is to be distinguished, as it appears to us, by the peculiar character of the discharges, which has been sufficiently dwelt upon, and by the degree of collapse and its early occurrence. Cases have been adverted to, which, at least in the choleric stage, could not be discriminated from ordinary cholera, excepting perhaps from their taking place at a season of the year when ordina- ry cholera is never observed; but it may be re- marked that no one would infer the existence of the epidemic from such cases, though he might be disposed to acknowledge that they belonged to it, if cases less equivocal were simultaneously pre- valent, and especially if they originated under the circumstances mentioned in the preceding page. Notice has been taken of sporadic cases which have occurred in several parts of the kingdom during the last year, and which have been re- ported in various publications. We have already 6tated our opinion as to the perfect identity of the group of symptoms in certain of these cases, and those which characterise the choleric stage of the epidemic. These cases have generally been fatal as cases of cholera, and probably on this account have attracted attention and been re- ported ; and hence what we should consider the experimentum crucis by which their essential alliance to the epidemic, as it has manifested itself in this country, or difference from it can alone be proved,—the intervention, or otherwise, of fever between the cold stage and recovery,—is neces- sarily wanting. We have been favoured by a gentleman of high character and attainments (Dr. Fenwick, of Durham) with a report of two cases regarded, at the time they occurred, as aggravated cases of the ordinary disease; both took place in the interior, under circumstances in which there was not the slightest ground to expect contagion, Vol. I. —52 » * and previously to there being any suspicion of the existence of the epidemic in this country. In one, the symptoms bore, unquestionably, a considerable resemblance to the choleric stage of the epidemic, but no fever supervened. The symptoms of the other shall be given in the words of the writer.— " The total, or nearly total suspension of the secretion by the kidneys ; the watery vomiting and stools ; the severity of the spasms; the shrunk and corrugated state of the skin on the hands and feet, and the blueness of his nails, persuade mc that his disease was of the spasmodic type- In him, moreover, a slow fever succeeded the original symptoms, and long retarded his reco- very." We need not remark that wc would not attempt to discriminate between such a case as this and examples of the epidemic, believing their character to be identical. This case occurred in the beginning of July, 1831. There is a certain form of the febrile stage, that which supervenes on a choleric stage, attended with extreme collapse, which the deficiency of the temperature and the circulation, the congested state of the conjunctiva from the very commence- ment of the fever, and the peculiar torpor of the intellect, would enable, as it appears to us, the observer to discriminate from any fever which we are in the habit of witnessing in this country, provided he saw the patient early and watched him throughout; but in the majority of instances the diagnosis can only be correctly drawn by coupling the preceding history of the case with the existence of fever, and with its character. 5. Appearances on Dissection. — The ex- ternal appearance of the body closely resembles that which has been noticed during life: the solids are shrunk, the surface is livid, the skin of the hands and feet is corrugated, the nails are blue, and the fingers often rigidly contracted. There is no evidence of any unwonted tendency to putre- faction, nor any characteristic fcetor from the ab- dominal cavity. In the head arc found marks of congestion, and even occasionally of extravasation. Such appear- ances were not of uniform occurrence in the dis- sections performed in Hindostan, but they were found very constantly in those made by Dr. Davy, in Ceylon ; and Dr. Keir, of Moscow, discovered in the Russian disease the blood-vessels of the brain and its membranes more or less turgid with blood, particularly towards the base, with a fluid effused into its convolutions, and more or less of serum in the lateral ventricles. In the thorax, the pleura and pericardium are found, as the serous membranes generally are in this disease, perfectly healthy, with the exception occasionally of an unusual dryness. The lungs are sometimes in a natural state, but more fre- quently gorged with dark-coloured blood, so as to resemble liver or spleen; or they have been found collapsed on each side of the spine, leaving the thorax nearly empty. This latter appearance Dr. Pollock, of the fifty-third regiment, explained by supposing gas to be extricated within the cavity of the pleura ; but the thorax having been opened in such cases under water, and no air having been found, Mr. Scott is disposed to ascribe it to a contractile power exerted by the viscus, sufficient to overcome the atmospheric pressure. Both sides 410 CHOLERA —[EPIDEMIC] of the heart are in general distended with dark blood, and the bronchi are frequently filled with mucus. In the abdomen, the vessels of the liver are often much congested, and pour forth blood copi- ously when incisions are made into the organ ; but this congestion is not uniformly found; the gall-bladder is turgid with black bile, and its ducts are sometimes constricted and impermeable, though occasionally in an opposite state. The peritoneum is often quite healthy, but the portion investing the alimentary canal has frequently an inflamed appearance from the exceedingly loaded state of the blood-vessels. This congestion is sometimes so great as to give the appearance of gangrene ; but by drawing the finger over the surface, innu- merable small veins may be found running in every direction, as in a preparation nicely injected, and the texture is found to be resisting and firm. This portion of the peritoneum, however, occa- sionally bears marks of actual inflammation, espe- cially if the patient has lingered long before death. It then presents a thickened appearance externally, and its colour varies from a pale vermilion, through all the deeper shades, to a dark purplish hue ; the former being chiefly remarkable on the surface of the duodenum and jejunum, the latter on the ileum where it terminates in the caecum. At other times, the whole alimentary tube, instead of this congested state, presents a blanched appearance both internally and externally. The omentum is sometimes healthy ; at others, it presents the same appearance of extreme vascularity as the perito- neal surface of the alimentary canal. The following appearances are discovered on laying open the stomach and intestinal tube. A white, opaque, and viscid substance is found ad- hering to the surface of some portions of the mu- cous membrane; and in many cases it is so abundant in the intestines as completely to fill parts of them of a greater or less extent The stomach and portions of the intestines are filled With a transparent or turbid serous fluid, and fre- quently the viscid matter mentioned above is found intimately mixed with the serous fluid, or floating in it in the form of flakes. The mucous membrane, except when inflamed, which it not unfrequently is, has an unnatural whiteness, is often soft and pulpy, and in general—especially in the stomach and small intestines—can be easily detached by scraping, in the form of a thick pulp, from the subjacent coat. These appearances are sometimes more or less partial; but some of them are generally found throughout the whole extent of the tube. They extend in some cases to the mucous membrane of the bladder and ureters, and have been found in two or three instances in that lining the bronchi. In one case only in India was the state of the spinal marrow examined ; and in that, strong in- dications of inflammation were detected in its sheath ; the case, however, was in some degree a mixed one. But Dr. Keir found, at Moscow, the blood-vessels of the vertebral column and spinal chord more or less loaded with blood, which was sometimes effused between its arachnoid and dura mater; partial softening of the substance of the spinal chord was sometimes met with, and marks of inflammatory congestion in the larger nerves were detected.* The dissections performed in Sunderland have generally furnished results corresponding with those obtained elsewhere. In the head, venous congestion of the brain and its membranes has been the most uniform and prominent appearance. Serum has been found in the ventricles of the brain and at its base ; but in many cases this has been in small quantity, not exceeding that frequently observed after diseases in which no affection of the ence- phalon was supposed to exist. In some cases. especially those in which death took place in a protracted stage, but occasionally in a rapid dis- ease, fibrinous depositions existed between the membranes. In the thorax the lungs have uniformly been found more or less gorged with blood, though in many cases the engorgement was in the posterior part, and probably resulted from position. These organs were generally crepitating, and free from structural change. Softness or flabbiness of the heart has been noticed in several instances, and both its cavities and the vena? cavae and coronary vein have been distended with dark-coloured blood. In the abdomen, the liver has been found gorged, but occasionally its condition was natural. The gall-bladder was generally distended, and the ducts were constricted, so that the viscus could not be emptied by pressure; but in some cases they were pervious. The abdominal veins have been found generally distended; but in several instances, the vena porta? and meseraic veins have constituted an exception to this rule, having been found empty. Vascularity and pulpiness of the mucous lining of the stomach have been frequently noticed; but the former has often been slight in degree, and observers have felt disposed occasion- ally to attribute it to the exhibition of mustard or other stimulants; whilst the latter has by no means been invariably found. The lining of the intestines has been found in many parts vascular and pulpy; but these appearances are not inva- riable, both lesions having been found wanting, and the pulpiness more frequently than the vas- cularity. The peculiar secretion has generally been found in the intestines. The kidneys have been observed to partake'of the general congestion of the venous system. The bladder has generally been found contracted, and either empty or containing a small quantity of urine. In the case mentioned, which was at- tended with trismus and other peculiarities re- marked in India, but not in other examples of the disease in Sunderland, it was considerably dis- tended. No softening or other disease of the spinal marrow, a little venous congestion excepted, was discovered in the few examinations of this organ made here. In concluding this rather unsatisfactory portion * Madras Reports, pp. 32, 34. Anderson on Cholera Morbus, Edinburgh Medical and Surgical Journal, vol. xv. Christie on Cholera, p. 47. Annesley, Diseases of India, 2d edit. p. 106, et seq. Account of the Appear- ances after Death observed at Moscow, drawn up by Dr. Keir. CHOLERA —[EPIDEMIC] 411 of our subject, we cannot refrain from expressing a conviction that symptoms during life throw much more light on the nature of the disease and Its appropriate treatment than appearances after death. 6. Nature of the Disease.—Many writers of great talent have preceded us in this very intri- cate branch of the subject, and much ingenuity has been displayed in the endeavour to trace all the phenomena of the choleric stage, which has been the principal subject of investigation, to a change in one part of the system. But it must be remarked that there is little accordance among medical reasoners as to the part of the body in which the phenomena of the disease are presumed to originate ; for the nervous system generally, the ganglionic portion of it exclusively, the blood itself, and the lining of the digestive canal, have each found advocates equal in ability to plead their cause.* The diversity of these views is a proof of the intricacy of the subject; and probably also, since they have all emanated from observing and inge- nious men, an evidence of the variable nature of the disease; each reasoner being perhaps influ- enced by that portion of the general phenomena of the epidemic which predominated in the cases it was his lot most frequently to witness. Their partial nature, too, may be in a considerable de- gree ascribed to the unfortunate influence of the expression, proximate cause, as a substitute for the more comprehensive term, essence or nature of the disease, on medical reasoning. Even those who affect to use it as an equivalent term for nature of the disease, are yet insensibly influenced by the words they employ. Amidst the crowd of phenomena presented to their notice in certain maladies, they often assume, on very insufficient grounds, that some one fact is the original of all others, and this they invest with the title of proxi- mate cause. If the facts related respecting epidemic choleric fever are compared with the explanations offered of them, it will be found that each medical rea- soner has attributed the commencement of the phenomena of the disease to an affection of some part of the frame, which affection unquestionably exists in a very great number of instances, but neither with that uniformity nor with that priority of time which can warrant us in concluding that it was the cause of all the other symptoms. It seems a rational supposition that the remote cause of a disease may act, in some instances, first on one, in others on another part of the system, from some local weakness or peculiarity of individual constitution, or from some specialty in the mode of application of the cause ; and yet that the dis- ease shall retain in each case such a resemblance to a common type as shall prove its identity. It is likewise supposable that the remote cause may make a simultaneous attack on more than one organ or part of the system. Complex diseases, such as fever, appear to furnish examples of both these cases. The real philosophy of medicine seems to consist in ascertaining the actual state * These are Dr. Kennedy and Mr. Orton for the first, Mr. Bell for the second. Mr. Annesley and others for the third, and Mr. Christie, with Roche and other French writers for the last. of the system of which symptoms are the signs; and if we can proceed through the medium of these signs and post-mortem appearances, to one sole change in one organ, the treatment is simpli- fied, and science and art are gainers. But there are diseases, and this seems to be one of them, in which we meet with a variety and complexity of pathological conditions, all of importance, and all to be kept in view in their treatment It is true that of these conditions some may arise from others according to known physiological laws, as dark- coloured blood from impeded respiration, and it is right thus to explain them when possible ; but the uniform endeavour to trace all to one primary change, or rather, as is more frequently done, to assume one change to be primary, and all other morbid states to be but emanations from it, is not only unphilosophical, but is too apt to tinge our practice with undue partiality. Whilst we deem that no one writer has attained, either by inferences drawn from symptoms, ap- pearances after death, or both, a knowledge of the affection of any one organ in cholera which can be properly termed a proximate cause whence all the other phenomena arise; or acquired precise ideas respecting the nature of the affection of many organs which manifestly participate in the disorder; it is gratifying to acknowledge that their labours have thrown much light on the condition of many parts, and that very great practical good has resulted from the information thus obtained. That the nervous system generally, and espe- cially the ganglionic and spinal nerves, and the spinal medulla itself, are affected, is manifest from many symptoms ; but whether this affection arises from a direct impression of the remote cause of the disease on these organs, or from irritation pro- pagated from the alimentary canal along the gan- glionic nerves to the spine, we are ignorant. Dr. Kier's able researches have shown that in some fatal cases inflammation of a portion of this sys- tem has existed ; but its precise pathological con- dition in cases which terminate favourably remains yet to be ascertained ; and it must be remarked, too, that in fatal cases this inflammation has not been always detected. The state of the sangui- ferous system is very remarkable : but here too we must feel some doubt whether the feebleness or almost complete arrest of the heart's action is a primary effect of the cause of the disease, or, as suggested by Mr. Bell, arises from the affection of the ganglionic system ; or, again, whether it re- sults, through the medium of this system, from the condition of the alimentary canal. Is the dark appearance of the blood to be explained by the feebleness of the action of the right ventricle, as a consequence of which but little blood is trans- mitted through the lungs and exposed to the influ- ence of the air 1 According to this view, which is suggested with diffidence, the imperfection of the respiratory process will arise from the same cause as in congenital malformation of the heart, such as the persistence after birth of the foramen ovale, or the aorta arising from both ventricles, in which a very small proportion of the whole mass of blood is oxydized. This hypothesis explains readily the dark appearance of the blood, its accu- mulation in the great veins of the viscera, the coldness and lividity of the skin, and the imper- 412 CHOLERA —[EPIDEMIC] fection of the respiratory process, which has been so ably illustrated by Dr. Davy. This gentleman was the first to show that the air expired by pa- tients in the choleric stage is colder and contains less than the usual proportion of carbonic acid ; and that this is the case even when the breathing is full, free, and rapid. The explanation offered is confirmed by an observation of Mr. Ellis, in his experiments on respiration, that "as the circula- tion declined, so likewise did the emission of car- bon, and, consequently, the production of carbonic acid." The thickened consistence of the blood receives a ready explanation from the loss of its serous part by the abundant discharge from the inner intestinal surface. There arc two morbid conditions of the lining of the digestive canal. In one it is in a state of manifest inflammation ; in the other it is white and pulpy, and easily detached from the subjacent coat. Is this latter condition the result of a dis- organizing inflammation which has itself passed away, or must we be content to describe the action which'has produced it by the very unsatisfactory and vague expression, disturbance of the function of nutrition ? This is a question rather of general pathology than one connected solely with this dis- ease; but it is one as yet undecided. The affec- tion of the alimentary canal is essential and pri- mary, if any part of the disease is so; and it were vain to attempt to trace it to a morbid condition of any other organ or system of organs. [The German and French physicians have paid considerable attention to an eruption of isolated granular pimples, chiefly met with in the two lower thirds of the ileum, which is said to exist in the vast majority of cases. Owing to this erup- tion, MM. Serres and Nonat gave the disease the name psorenteria. (Art. Cholera, par A. Nonat, in Diet, den Etudes Mcdiculcs, torn. iii. p. 416: Paris, 1839.) Examination of the blood of a choleric patient by M. Andral, (Hematologic Pathologique, Paris, 1343,) showed that there was no augmentation of the fibrinous element, as is observed in severe phlegmasia? of the digestive tube. The proportion of fibrin was 3-3; of globules 118; and of solid matter of the serum 88.] The general suspension of secretion, which is complete only when the collapse is extreme, ap- pears to result from the disorder of those systems, the nervous and vascular, on which this important function depends. The apparent anomaly pre- sented by the continuance of the cutaneous and intestinal discharges amidst the general suspension of secretion, is well explained by Mr. Bell's dis- tinction between Jhis function and exudation or exhalation. (Treatise on Cholera Asphyxia, p. 56, 57.) Were we to endeavour to illustrate in a few words the nature of cholera by examples drawn from analogous diseases, we should say that its choleric stage presented in a more intense degree the initiatory collapsed symptoms of certain bad fevers before re-action had taken place, combined with excessive gastro-intestinal irritation ; whilst the febrile stage bore a very close resemblance to such fevers after the establishment of re-action, or in many cases was, at least in external character, perfectly identical with them. That the whole scries of phenomena results from the action of a morbific poison on the body, there can be no doubt; but as yet, as in the case of other fevers, we are ignorant of the precise nature of the primary change effected by it in va- rious organs or systems; and it is to be feared that till more accurate ideas are attained respecting the pathology of fever in general, this ignorance will remain. In the febrile stage, we would re- mark, there are indications by no means equivocal, of inflammatory affection of the brain, and occa- sionally of other organs, the analogy to fevers in general being in this respect preserved. Were we to judge solely from what we have ourselves ob- served of the commencement of the disease, we should consider the alimentary canal to be the part of the frame which first felt the influence of the poison ; but we should consider the condition of the nervous and vascular systems much too in- tense in degree to be merely sympathetic of the state of the stomach and bowels. Many cases, moreover, which have been reported from abroad, particularly from India, lead to the opinion, that in various instances the nervous system is prima- rily affected. 5. Proportionate mortality. — The mor- tality during the early prevalence of the epidemic in India in 1817 and 1818 was very great, but either from the abatement of the intensity of the disease, or from the improvement of the method of treatment adopted by our medical men, or, as is more probable, from the co-operation of both these circumstances, it was subsequently very much re- duced. There is no disease in which unassisted nature seems more powerless than this. We learn from the report to the Medical Board at Bombay, that there is reason to believe that of 1,294 cases which received no medical assistance, every indi- vidual perished; and it is added, that it is not ascertained that any case has recovered in which medicine had not been administered. From this appalling statement, it is gratifying to humanity to turn to the following records. According to the documents collected by the Madras Medical Board, the number of deaths caused by it in the army of that presidency during 1818 and the four subsequent years, was 4,430, of which 695 oc- curred among the European troops, and 3,735 among the sepoys. The number attacked was 19,494, namely, 3,664 Europeans and 15,830 na- tives. The average strength of the army during the period included in the reports being 10,112 Europeans and 73,254 natives, it follows that in five years 23£ per cent, of the troops were at- tacked, and that of these 22-J per cent, were car- ried off, or 5£ per cent, of the whole force of the army. This statement, though sufficiently dis- tressing, is still a proud monument to the skill of the medical men employed, and to medical science in general. We hear, in different situations, of rates of mortality infinitely lower than this. Dr. Burrell, surgeon of the 65th regiment, reports, for instance, from Seroor, that out of sixty cases he lost four, being at the rate 6-6 per cent. ; whilst Mr. Crow, at the same station, makes the mortality much less, declaring that the disease is not fatal in more than one in a hundred of those who are early succoured. Dr. Burrell found, too, that of a cer- CHOLERA —[EPIDEMIC] 413 tain description of cases, those attended with vio- lent spasms, he saved eighty-eight out of ninety. (Bombay Reports, p. G8, &c.) In taking these estimates into consideration, we must always re- collect, however, that in epidemics there is often a very wide difference in the gravity of the dis- ease at different points or in different years,—in- deed, sometimes at nearly the same point and in the same year ; so that when we hear of an ex- tremely small loss in proportion to the number attacked, long experience does not permit us to doubt that in such a case the type of the disease has been very mild. The ravages of the disease in civil life, amid a comparatively unorganized population, where prompt assistance could not always be rendered to the sufferers, furnish a considerable contrast to this statement from the British army, and strongly confirm the opinion expressed, of the importance of early treatment in a malady so rapid in its course, and in which the efforts of nature are so impotent. At Busheer, in the Persian Gulf, we learn from Moreau de Jonnes, that in 1821 a sixth part of the inhabitants perished; and at Bassora, in the same year, Mr. Rich informs us that eighteen thousand died, of whom fourteen thousand perish- ed within a fortnight The number attacked in Moscow from September 1830 to January of the following year, was 8,130, of which perished 4,385, or 54 per cent* In the small town of Redislscheft, of eight hundred sick, we learn from Dr. Reimann, that seven hundred died in one week. The greatest success which has attended the treatment of the disease in the Russian em- pire, so far as the records have reached us, oc- curred in the district of Orenburg, the number attacked being 3,590, of whom 865 perished, or about 24r'ff per cent., a result creditable to the vigilance of the Russian government, and to the skill and care of the medical men employed. The treatment adopted was that of our Indian practi- tioners ; bleeding, calomel, opium, warmth, and friction.-j- The disease having, there is every reason to think, run its course through the town in which these observations were written, it may not be un- interesting to mark the amount of ravage which it has inflicted. The town comprised under the general name of Sunderland consists of three parishes, viz. Inhabitants. That of Sunderland, containing.... 17,060 Bishopwearmouth............... 14,825 Monkwearmouth and its immediate dependencies, in all which the dis- ease existed.................. 8,850 Total.......... 40J35 This computation is exclusive of certain out- townships, to which the disease did not extend. The total number attacked with epidemic cho- leric fever out of this population from its manifest appearance on the 26th of October to its cessation in the middle of January, was 534, of whom 202 * Memoir of Dr. Loder, physician to the Emperor at Pt. Pnti-rsbnrgh. dated January letf 1, and read at ihe Aca- demy of Medicine at Paris. t Substance of a report published by the Supreme Me- dical Board of Russia. 2x« perished. These deaths are computed, with all the accuracy which the parish registers and other sources of information permit, to have occurred in the following proportions :— In Sunderland..................... 156 In Bishopwearmouth............... 21 In Monkwearmouth................ 25 Total............."202 From this statement it is manifest that, if the disease pursue the same course elsewhere that it has done in Sunderland, the danger to a popula- tion is to be estimated less from their numbers than from various circumstances in their condi- tion, and particularly from the proportion which the labouring class bears to the rest of the com- munity ; for the parish of Sunderland, in which the mortality was in so much higher a ratio to the population than in the other parts of the town, is that in which the proportion of the labouring poor is greatest; though their situation is by no means so comparatively wretched as persons un- acquainted with the habits of the labouring class in general, (and especially of that portion of it dwelling in sea-port towns,) and consequently destitute of the means of accurate comparison, have taken pains to describe. Besides the smaller number of the labouring class residing in Bishop- wearmouth, there are various circumstances, such as its situation being higher, its streets wider and better ventilated, &c. which probably contributed to its proportionate exemption from the disease. Of the small number of its population who suf- fered, it must be remarked, moreover, that a large proportion lived in an inconsiderable part of the parish, at its outskirts near the river, called Ayre's Quay, inhabited almost exclusively by the labour- ing class. In this small locality nine out of the twenty-one deaths occurred. It should be ob- served, too, that in Monkwearmouth, situated on the north bank of the Wear, the disease was con- fined almost exclusively to the lowest, dirtiest, and most populous district, situated near the river, called the shore. It is a fact of some importance that of the vic- tims of the disease, seven only, so far as we have been able to discover, were, in point of situation in life, at all above the labouring class. A simple calculation shows that the mortality amounted to one in two hundred and one and a fraction of the whole population in which the disease prevailed; that of Sunderland was as one to about a hundred and fifteen of its population ; that of Bishopwearmouth as one to seven hun- dred and six, and exclusive of Ayre's Quay, as one to somewhat more than one thousand ; and that of Monkwearmouth as one to three hundred and fifty-four. There is nothing very alarming in such a rate of mortality as we have described ; it is high on the number attacked, but low on the amount of population : and the former circumstance and the rapidity of the disease will probably be found to constitute its most appalling features, if its course elsewhere in this country resemble that observed [ here. Other epidemics which visit us exceed it whether we regard the number or the quality of victims, in the amount of evil inflicted ; but none I is to be compared with it in fatality in proportion 414 fJHOLER A —[EPIDEMIC] to the number attacked, or in the rapidity with which it accomplishes the work of destruction. Our friend Dr. Ogden has furnished us with the following calculation, which is interesting pro- vided the results of similar Calculations made elsewhere in this island correspond with it; for it will thus be shown that in one point of some importance, the proportion of the sexes attacked, the disease here observes a course directly the reverse of that witnessed elsewhere in its progress. Cases of cholera, known to be such, buried at Sunderland between the 28th of October and 22d of December:— AGE. MALES. FEMALES. TOTAL. 15 and under.. ..12 . .. 13 .. . 25 From 15 to 50. ..14 . . . 33 . 47 ...37 . .. 36 . 73 63 82 245 Besides showing that at the period of middle life the number of female victims of the disease is double that of males, and that at the two ex- tremes the numbers are as nearly equal as pos- sible, this table shows how large a proportion of aged persons the whole amount of mortality com- prises, these constituting more than one-half of the total of deaths. The preponderance of attacks in females over those in males at the period of middle life is pro- bably to be explained partly in the manner sug- gested by Dr. Ogden, that the dress of the latter sex furnishes a better security against cold than that of the former; and in part by the circum- stance that males at the working period of life are better nourished than females, being frequently the only members of families of their class of society who partake of animal food. For obvious reasons, we abstain from any sta- tistical details connected with neighbouring towns in which the disease is, at the time this is writing, only in progress. [From some estimates made in England by Sir David Barry, it would appear that 38-5 per cent of the cholera patients died. In 1832, probably 5000 perished in London, and in Great Britain somewhat more than 20,000. In Paris, during the epidemic of 1832, more than 18,000 fatal cases are said to have occurred. In the Russian provinces, the mortality was 58-6 per cent In Naples, it was estimated at six to ten. In Paler- mo, it was dreadful. Of a population of 150,000, about 30,000 of whom, it was supposed, left the town at the breaking out of the complaint, 25,000 died, or about a fifth part of those who remained. In some of the towns of the United States, the mor- tality was taken as accurately as was practicable It is thus stated by Professor Jackson, of Phila delphia: Places. Population. Cases. Deaths. Ratio of cases to population. Ratio of deaths to cases. Ratio of deaths to population. 32,000 28,000 240,000 160,000 5783 4385 5547 2314 3292 1853 2782 935 1 in 5+ 1 in 6-5 1 in 25-3 1 in 70 1 in 2-5 1 in 2-5 1 in 2 1 in 25 1 in 10-5 1 in 15+ 1 in 15-5 1 in 173-2 New York,...... From the epidemic at Paris, attempts have been I made to calculate the probability of death and recovery in Asiatic cholera. From these it would appear, that the daily rate of mortality, in the first 12 hours, was 16 per cent.; in the next 12 hours, (12-24,) 37 per cent.; in the 2d day, 11 per cent.; in the 3d day, 8 per cent. The mor- tality of cases of cholera, in Paris, was 49 per cent. The force of mortality attained its maxi- mum in cholera by the 21st hour, (18-24 hours;) the maximum intensity of smallpox being attained in days 10-15; of phthisis, in 6-9 months. The danger of cholera decreases as the time advances: the longer a cholera patient lives, the more likely is he to continue to live. Half the deaths happen in 24 hours. The following table by Mr. W. Farr shows the probability of recovery from the severer attacks of cholera at the end of 12 hours, and of one, two, and three days: Caje;. To rec'r. Tn di* Probability of rec"jr. 0 hours, 10,000 5093 4907 •509 nearly 1 to I U 9185 5(113 4(lfrf 555 — ]-3 to 1 1 day, 7(316 5013 25^3 ■i;t>;> — 2 to 1 2 67113 50'3 noo •750 — :i to 1 3 0991 5093 ll'.id ■?09 — 4 to 1* 6. Extent of Diffusion, and Causes.—On the first branch of this subject we cannot be wrong, so frequently have its details been pre- sented to the public, in assuming considerable * [Practice of Medicine, i. 143.] knowledge on the part of our readers ; or in re ferring those who may wish for more minute in- formation than is ordinarily possessed or than we have space to give, to the admirable chronological table of M. Moreau de Jonnes. The present epi- demic originated in the district of Nuddea, and perhaps in some other parts of the Delta of the Ganges, about the end of May or the beginning of June, 1817. It did not during that year ex- tend beyond the territory of Lower Bengal; but in 1818 and the early part of 1819 it diffused itself throughout the extreme length and breadth of the Indian peninsula, moving in lines more or less diverging, and attacking in succession places generally more remote from the seat of its origin, (though striking deviations from this rule were occasionally observed,) and situated in various directions from it; but leaving untouched many districts placed between its lines of movement. Its progress along the lines it selected was won- derfully uniform, being for some successive months at the rate of about one degree in a month. As early as 1818 it extended itself beyond the boundaries of Hindustan into the Burmese empire and other territories of Eastern Asia, and, making gradual progress through these extensive realms, reached China in 1820, and in the following year visited the numerous and populous islands situated in the Indian Archipelago. The Isle of France suffered its invasion in 1819, and some CHOLERA —[EPIDEMIC] 415 cases occurred in the same year at one point in Bourbon, in which island it has not since ap- peared. In 1821 it extended along the shores of the Persian Gulf, and during this and the follow- ing year spread through parts of Arabia, Persia, Mesopotamia, Syria, and Judea, and closely threatened Europe. It appeared in the Russian territories in 1823, at Saillon, Ghillan, Orenburg, and Astracan ; but its further northern and wes- tern progress was for a time arrested. It, however, re-appeared in Orenburg in 1828, and again in 1829, and in 1830 advanced through the southern provinces of the Russian empire, till it reached Moscow on the 28th of September of that year. Its subsequent progress through Russia, Poland, the Austrian dominions, the north of Germany, and in England, is too familiarly known to render it needful that we should present its details to the reader. The space traversed as yet by this extraordinary epidemic may be conceived from the following simple calculation. The Philippine islands form (so far as is known) the eastern, and Mauritius the southern, boundary of the disease. The former lie in east longitude 125°, and the latter is in south latitude 20°. Archangel is the most northern, and the vicinity of Edinburgh the most western point to which it has extended. The former is in north latitude 64°, the latter in west longitude 3°. Hence it is manifest that the dis- ease has passed over 128° of longitude and 84° of latitude. [On the 26th of October, according to the above account, it first appeared in Sunderland; in Janu- ary 1832, it was in Edinburgh ; and on the 10th of February, in. London. Its progress in every town in the British islands visited by it has been accurately traced by Professor Graves, of Dublin, (Dublin Journal of Medical Science, January, i840; reprinted in the American Medical Li- brary, vol. iii.: Philadelphia, 1840.) It is singu- lar that there, as elsewhere, it left a number of places untouched, and others were but slightly affected. Cholera first appeared in Paris in March, 1832, and, with great rapidity, various parts of France were attacked. From England the disease soon passed to Ireland, and appeared in Dublin in March, 1832. On the 8th of June, 1832, it was first seen on this side of the Atlantic in Quebec; and on the 10th it appeared at Montreal. On the 21st of June, it suddenly and unexpectedly ap- peared in New York,—all the intermediate cities on the seaboard of the provinces of New Brunswick and Nova Scotia, and of the States of Maine, Massachusetts, and Rhode Island, remaining wholly exempt. On Thursday, July 5, the first decided case manifested itself in Philadelphia. This city suffered much less than Montreal, Quebec, and New York. The disease spread in various directions, visiting Albany, Troy, New Brunswick, and Rochester, in July; Baltimore, Washington, and Boston, in August During the same months, it was prevalent in several parts of New Jersey and Delaware. About the 1st of October it suddenly broke out at Cincinnati, and nearly simultaneously at Madison, Louisville, ai I St. Louis; and by the latter end of the month, it reached New Orleans. Leaving the Ohio, it visited Tennessee, Illinois, Indiana and Kentucky, — Lexington, Maysville, and some other towns, suffering severely. During the same year, the disease visited Campeche, where it was exceed- ingly fatal,—4000, out of a population of 20,000, falling victims to it. It also visited the Havana early in 1833, but never reached any other West India island ; nor did it extend to Guiana, Deme- rara, or any of the embouchures of the great South American rivers, Amazon, Orinoco, or La Plata. In 1834, it revisited many of the cities of this country, which had previously suffered, and spread to others that had been left untouched; yet singular cases of entire immunity were met with. Two of these may be mentioned as examples Fredericksburg on the Rappahannock, and on the great road from Washington to the South, may be said to have escaped almost wholly; and whilst the disease was prevailing at Richmond, and the inhabitants of Charlottesville, and of the Univer- sity of Virginia, in its vicinity, were daily ex- pecting a visitation, not a case occurred, although travellers daily arrived from the afflicted city in the public stage. Philadelphia and Baltimore both suffered again, but not severely, in 1834. Charleston also was visited, with most of the southern towns. The disease recurred, indeed, at intervals, for a year or two, but ultimately disap- peared, not to return, unless the same endemico- epidemic influences should exist, which favoured its progression previously. In like manner it oc- curred at Marseilles and Toulon in 1835; at Naples in 1836 ; and at Bona in 1837. Mar- seilles was attacked, for the third time, in the same year, and it re-appeared in the autumn at Berlin, Prague, and Danzig. The number of persons attacked in the Lombardo-Venetian States, in 1836, was estimated at 100,000, of whom 55,000 died. In the latter part of 1837, the in- habitants of the British metropolis were alarmed by the appearance of cases at Limehouse, which were pronounced by some to be genuine Asiatic cholera; but, by others, to be emanations from " alarmist cholera-hunters." The disease, if it existed, never certainly became epidemic. (See the writer's Practice of Medicine, 2d edit i. 132: Philad. 1844.)] The questions naturally occur, what agent first generated the disease ? and what has subsequently diffused it over so large a portion of the globe ' The first question must be answered by a sim- ple statement of the facts, that it originated in the district mentioned after an unusual disturbance of the seasons with respect to alternations of heat and moisture ; that it made its appearance at the commencement of a rainy season, so excessive that the Gangetic Delta was converted into a sheet of water; and that the very first point in which it was observed was the district of N uddea, noted for the endemic prevalence of cholera, where the whole year had been rainy, and during everv week of April and May (it began to mani- fest itself in the latter month) there had been a succession of thunder-storms. From this district it appeared to diffuse itself over the rest of Hin- dostan, its progress throughout the country being accompanied, as Mr. Orton informs us. by circum- stances somewhat similar to those which attended ite origin. 416 CHOLERA —[EPIDEMIC] The second part of the question cannot be dis- missed so lightly. As is well known, the doubt and difficulty regarding the subject exist chiefly with respect to the share which contagion has had in its diffusion; and this question we shall endeavour to discuss as succinctly, and certainly as dispassionately and fairly as possible. That our opinion, in the course of the investigation, has fluctuated, we feel it no discredit to avow. This fluctuation was either prior to the appear- j ance of the disease in this country, or to our having it a sufficient length of time under ob- servation to enable us to attain a settled conclu- sion ; and when we show the conflicting nature of the evidence from which, under the circum- stances mentioned, a conclusion was to be drawn, it will be manifest that fluctuation or total scepti- cism must have been it* result. As this evidence consists of facts already before the public, we shall, for the sake of brevity, rather refer to than detail them, classing them, as nearly as their nature admits, according to the very precise rules laid down by Dr. Alison for discriminating the operation of contagion. 1. Strong evidence of a disease being contagi- ous is furnished by its appearance in communities previously healthy shortly after the arrival of per- sons from infected districts, who are themselves suffering under the disease, or who sicken of it soon after their arrival. A striking example of this sort is related in the Madras Report of the appearance of the disease at Jaulnah, after the arrival of a detachment there from Nagpore, then infected, and its subsequent diffusion from the former place to the towns of Malligaum and Hydrabad, and various villages. Other cases, though few so striking as this, might be selected from the Indian records, but we prefer referring to examples which occurred in the Russian epidemic. In the fortress of Razupna, in that of Iletsk, and, towards the close of the epidemic, at Caramala-Gubeerra, all in the govern- ment of Orenburg, the invasion of the epidemic coincided, in point of time, with the arrival in them and sickening of persons coming from in- fected places. It should be remarked, however, that in these cases communication was not al- ways traced between the individuals subsequently and those first attacked; and in the case at Razupna, it is distinctly mentioned, that of the individuals who visited the man first seized on his arrival from Orenburg, then infected, not one took the disorder.* Into the opposite scale, that of the non-con- tagionists, may be thrown facts which tend to prove that it has originated in districts previously healthy without any ascertained communication with infected persons, and that, on the other hand, the most ample intercourse has existed on various occasions between healthy and infected communi- ties without the former having participated in the disease. Its introduction into the city of Oren- Dttrg in 1829 was not only not traced to commu- nication from an infected district, but a conjecture :hat it might have been introduced either by the * On the Asiatic cholera as it appeared in R'issi.i in the years lfcH29 and !»::>id. CHOLERA —[EPIDEMIC] 417 different quarters is more contradictory than the comparative liability to it of attendants on the sick and other members of the community. From India the testimony on this head is so conflicting that no conclusion can possibly be drawn from it: a state of complete scepticism is that in which it leaves the mind of an honest inquirer after truth. That from Russia is not of a much more decisive character; such as it is, we shall present it to the reader. During two months, observes Professor Licb- tenstadt, while the disease prevailed at Orenburg, and two hundred and ninety-nine patients were admitted with cholera into the military hospital, the personal attendants on the sick remained entirely exempt from the disease. They consist- ed of one hospital assistant, six pupils, as many Baschkir lads, and fourteen hospital servants, in all, twenty-seven ; and their duties were to per- form bloodlettings, apply leeches, poultices, and frictions, and administer baths and the like, so that they were compelled to be constantly breath- ing the exhalations from the bodies and clothes of the sick, as well as to touch and handle them. The washerwomen of the hospital likewise escaped ; a class of individuals, who, it is well known, are extremely apt to suffer from contagi- ous diseases. On the other hand, Drs. Russell and Barry in- form us, " that the number of medical men and hospital attendants attacked with cholera during the present epidemic, in proportion to the whole employed, and to the other classes of society, has been beyond all comparison greater here (St. Petersburgh) than in India under similar circum- stances; twenty-five medical men have been al- ready seized, and nine have died out of two hun- dred and sixty-four. Four others have died at Cronstadt, out of a very small number residing in that fortress at the time the disease broke out there. Six attendants have been taken ill at a small temporary hospital behind the Aboucoff." With regard to this last circumstance, it is not stated, as in another report by the same gentlemen (not published) bearing date 4-16 July, that "in the great Aboucoff hospital, where there were no cholera patients, but to which a temporary cholera hospital was attached behind the building, ten persons residing within the area of the establish- ment had been severely attacked up to the 12th instant (N. S.) with cholera." This leaves a very different impression, and not being aware of what is meant by " the area of the establish- ment," we cannot form an opinion how it may or may not bear towards the side of contagion. In the Inst-mentioned report, those gentlemen also state, that in the Military General Hospital, in which four hundred cholera patients had been admitted from distant quarters, up to the morning of the 13th, "one attendant had been attacked." But one attendant where so many cases had been treated ! These specimens, taken from an immense mass of foreign evidence, will suffice to show its con- flicting nature on points essential to the decision of a much litigated and very important question. There are certain branches of the subject, such as the immunity apparently afforded by seclusion, which we have designedly omitted; partly be- Vot. 1___53 cause they were unavoidably exposed to sources of fallacy, and the testimony regarding them was of the same conflicting nature as the specimens which we have already presented to the reader; and partly that we might preserve space for an examination of the question, how far the general progress of the disease favours the opinion that human intercourse has been the instrument of its diffusion; and for the narration of certain facts illustrative of the general question which have fallen under our observation. The progress of the disease on the great scale having been tolerably regular both geographically and chronologically, — that is, its having passed from country to country without leaving inter- jacent countries untouched, and those infected having been so in some proportion, in point of time, to their distance from its original source,— has been appealed to by two parties as evidence of the accuracy of their opinions ; the one seeing in it a proof of a continuous stream of epidemic influence flowing from the point where the disease originated; the other a transport of the malady by human intercourse from the same source. To the opinion of a flow of epidemic influence, have been objected, and apparently with justice, the slowness of the progress of the disease; that it has extended its territory in spite of the opposi- tion of continued and violent monsoons; and that, notwithstanding a degree of general regularity of progress, there have been anomalies observed in its course, such as its having left districts un- touched whilst all around them were suffering, utterly irreconcileable with the opinion advanced. On the other hand, circumstances have been observed, which render it almost equally question- able whether contagion has been the sole instru- ment of its diffusion. It has been asserted by the advocates of the ex- clusive operation of this principle, that the disease has always been found to move in the line of human intercourse, and it must be acknowledged that, whilst so migratory an animal as man in- habits the earth, it cannot well do otherwise ; but if it is meant to be asserted that its diffusion has been in proportion to the intercourse between in- fected and healthy districts, the assertion is by no means supported by facts. Its appearance at Madras, for instance, whither according to this doctrine it ought to have been conveyed almost three months earlier by trading vessels from the infected districts, was simultaneous, as Mr. Bell informs us, with its origin in parallel latitudes in the interior. It did not reach Ceylon, to which, on the contagious principle, it ought to have been conveyed at a much earlier period, by shipping from infected points of the coast, until it had pre- viously gained the nearest point to it on the con- tinent, about Adam's Bridge, and had been long prevailing on both coasts of the peninsula. (Or- ton on Cholera, 2d edit. p. 332.) Unfrequented villages have been observed to suffer the invasion of the disease as early as the marts of intercourse and commerce; thus, from a statement of Mr. Orton, it seems to have reached some villages on the north bank of the Cavery, — detached from any frequented road, and considerably to the east- ward of Trichinopoly, — quite as soon as thia large and frequented town, whither it appeared 418 CHOLERA—[EPIDEMIC] to have been imported by a company of sepoys. (Ibid. p. 331.) Its movement along navigable rivers has been dwelt upon as evidence that human intercourse has been the means of its diffusion ; and it is an argument of some force in showing that such in- tercourse may have occasionally been instrumental in effecting it: but when we are informed by Mr. Orton that the disease manifested this predilection for the course of rivers in the peninsula of Hin- dostan, " where navigation is scarcely carried on, even to the most trifling extent, on any river, and scarcely an instance can be mentioned of a great road running on the bank of a river, for they al- most all cross them," we must acknowledge that more weight has been attached to the argument than it is calculated to bear. The disease, in its general course, has mani- fested a preference for one line of movement, and has rejected another, though there has been no striking difference in the amount of human inter- course between the two directions to explain the preference and rejection. Its progress in a north- western direction across the European continent has been briefly described, and is fully known to the reader. For three years it prevailed in the Ottoman territories bordering on the Levant; and it would appear, without any deficiency in the productive (or at least destructive) force of those germs of which we have recently heard so much; for in November, 1822, it numbered 4000 victims in eighteen days in Aleppo; yet it has not pene- trated into Turkey in Europe, and other extensive realms on the shores of the Mediterranean. As- suredly this could not arise from want of means of transport, and few will be disposed to ascribe it to the perfection of the quarantine department of the Sublime Porte. Since its appearance in this country a similar predilection has been dis- played ; for we find it at this instant a hundred and forty miles to the north-west of Sunderland, whilst six miles south is the extreme distance to which it has reached in that direction ; and from the point which it attained, Seaham Harbour, after attacking eight persons and destroying three, it has since vanished. A circumstance which may be urged against the exclusive operation of contagion, (and it is against attributing too much to one principle alone that we are arguing,) is the unusual pre- valence of disease, bearing a considerable relation to epidemic choleric fever, which generally occurs prior to the appearance of this in any given locality. The facts which might be mustered in proof of the antecedence of such disease are far too numerous and consistent to be accidental. Ordinary cholera, sporadic cases not distinguish- able from the epidemic, excepting by the isolated manner in which they occur; epidemic diarrhoea; gastric and intestinal fever, have been observed in so many situations and by so many individuals, from 1817 to the present instant, to have been the precursors of the disease, that there cannot be a reasonable doubt of the accuracy of the observa- tion. During the last year the prevalence of these affections in various parts of this country has been matter of familiar remark among medical men, and many of them have very properly taken care to record their observation. (See Dr. Burne's Dispensary Reports, in the Medical Gazette for July 2d, and July 16, 1831.) In this neighbour- hood, what Mr. Orton felicitously terms the skirts of the approaching shower were manifest long before the epidemic made its formal inroad. Or- dinary cholera was most unusually prevalent; whilst cases of disease, certainly not distinguish- able by symptoms from the epidemic, ocurred on the 5th, 8th, 14th, and 27th of August; and cholera continued to be very prevalent and severe throughout September. The cases which occurred in August were not matters of secrecy, but were the subject of conversation among the medical men of the place; and the writer frequently made the remark, that we were partakers of an inferior degree of the epidemic influence which existed on the continent. But certainly at the time he did not (nor does he yet) ascribe them to imported contagion; nor did he then conceive that we had, properly speaking, the epidemic among us. What- ever view others may now feel disposed to take of these cases, it would be difficult for them to suppose that the case we have mentioned, as hav- ing occurred in the interior in the beginning of July, was attributable to foreign importation. Under either view, as it appears, whether we conceive that a current of contagion flows towards a district, or suppose the disease to be engendered there by indigenous causes, (not customary ones certainly, any more than those which existed in the Delta of the Ganges in 1817,) and then to be invested with some contagious property, which observation of the disease will induce most candid persons to admit it possesses, it requires the opera- tion of two principles to explain all the facts of the case ; for even on the first supposition we are compelled to imagine this double operation to be in progress,—a current of contagion to be flowing from one point, and a nidus for its reception to be preparing in another. We have been led to the conclusion that the disease possesses a contagious properly, from having observed that a considerable proportion of attacks have taken place in individuals shortly after communication with the sick, or exposure to emanations from the dead bodies, and, in part, from a few examples having occurred of the dis- ease appearing in parts of the town or neighbour- hood where it did not previously exist, on the sickening there of persons who had communicated with the infected districts ; but at the same time we beg to remark that there are circumstances which tend to show that this property is ab- stractedly feeble in degree, and to render it more than questionable whether it can be the sole agent in diffusing the disease. This opinion is founded on the singular ano- malies observed in the course of the disease, and which still mark its progress, and on the follow- ing considerations:— 1. Members of that class of society which has manifested the strongest predisposition to the dis- ease have been very long exposed to the emana- tions from the sick under circumstances the most favourable to the propagation of the disease, with- out being infected. 2. No death, and scarcely an attack of serious indisposition, has occurred among the medical men, though they have spent hours in the pa- CHOLERA—[EPIDEMIC] 419 tients'chambers, assisting in frictions and other! offices usually performed by nurses, and from the fatigue they were undergoing might be supposed to be peculiarly obnoxious to contagion. 3. Medical practitioners have not in any ascer- tained case conveyed the infection in their clothes to patients whom they were attending for other diseases, or to their families. Certain of them bave mingled unreservedly with their own families after long attendance on cholera patients, without any indisposition, however slight, occurring in consequence. It is proper, however, to remark that two cases have occurred, one of them a fatal one, which might be attributed to the intercourse of medical men with their families. 4. When the disease has appeared in a private family in a situation in life above the labouring class, it has been confined, so far as the writer's knowledge extends, and he is of opinion that he is acquainted with the circumstances of all the cases of the kind which have occurred, to the individual first attacked, and has not in any in- stance spread to the other members of the family ; nor have in these instances nurses or other casual attendants on the sick suffered, though belonging to a class more obnoxious to the disease. 5. The agricultural villages in the immediate neighbourhood of Sunderland, which had through- out the whole progress of the epidemic the most unreserved intercourse with us, remained and still remain exempt from the disease. The populous village of Deptford, situated near the river, at the distance of half a mile from Ayre's Quay, where the disease was very prevalent and fatal, and hav- ing the most constant communication with it, partakes of this exemption.* The town of South Shields, containing nearly 14,000 inhabitants, and distant from Sunderland but seven miles, remained exempt from the disease (with the ex- ception of two cases, stated to be very slight, and not traceable to any communication with this place,) during the whole of its epidemic pre- valence here, though calculations have shown that eleven hundred persons pass weekly between the two places. Explanations have been offered of this exemption ; but they appear inadequate if we suppose this disease transmissible to every locality by human intercourse, since typhus, scar- latina, and other infectious diseases frequently prevail there to a great extent. Even to the pre- sent moment, (Feb. 2, 1832,) though its inter- course with Newcastle and other infected places has been incessant, but seven cases have occurred, and, as our intelligent correspondent there re- marks, « We have not as yet got the disease as an epidemic, the cases have been so few and far between." 6. Though the disease has appeared, in certain cases, to be transferred to previously uninfected districts by spreading from persons who had sickened there after arriving from places where the disease prevailed, yet facts have occurred which tend to show that the sickening of such persons and the diffusion of the disease have, at least in some instances, been mere coincidences. ♦There were two slight" case* in this crowded villape inhabited by tin: r lass most susceptible ot the disease, out it did not spread from them to the rest of the popu- lation. ' A woman of the name of Liddle, who lived in Sunderland, sickened at the town of Houghton- le-Spring, six miles from this place, and died on the 5th of December. The next case occurred on the 8th of the same month, in the person of a female named Cockburn, who lived a considerable distance from the house where Liddle died, and in a different street, and had had no communica- tion with her, direct or indirect; the family of the house in which the death occurred, and the per- sons who surrounded Liddle in her illnes, escap- ing all infection. In many other instances in which the disease has appeared in a mining dis- trict or village, (and it has spread extensively in such situations,) the first cases colild not be traced to communication with infected places. In certain cases, however, and we shall m'ention that of Hetton, the persons first seized had been in com- munication with infected districts. 7. On the first appearance of the epidemic in certain places, several have been simultaneously attacked ; at Earsden Colliery, for example, thirty- two. On its first breaking out here, it manifested itself in three distinct points, between which no communication could be discovered; and the at- tacks in two of these points were stimultaneous. It could not be traced from any source of infec- tion to the individuals first attacked. In many instances, likewise, instead of residents in the same house being successively attacked, its inva- sion of several has been simultaneous. 8. There were feelings experienced by various persons, either otherwise in perfect health, or labouring under complaints distinct from the epi- demic during its prevalence here, such as spasms, thrilling sensations of the extremities, and various affections of the nervous system, which appeared to betoken the influence of some cause more ge- nerally diffused than contagion ; since many per- sons thus affected had not been exposed to any source of infection. The writer was at first dis- posed to attribute these occurrences to the in- fluence of imagination; but they occurred in too many instances, and in persons too little sensitive and imaginative, to allow him to adhere to this explanation. After assigning these reasons for questioning the exclusive operation of contagion, we think it right to remark that epidemic choleric fever has committed fearful ravages in some families, espe- cially in those of which the circumstances were calculated at once to give intensity to the causes of the disease, and to render the individuals com- posing them more obnoxious to the action of such causes. Of one family seven were attacked with the disease, of whom five perished. The case of the first individual of the series constituted one of the sporadic cases, and it is incredible that the next in succession should have received infection from him, four months having elapsed between the dates of the respective attacks ; but it is pro- bable that contagion was transmitted from the second and subsequent cases, the diseases having commenced on the following successive dates, the 11th, 12th, 13th, 16th, 17th, and 20th of Decem- ber. The case which occurred on the 20th was that of an infant, aged thirteen months, taken from the breast of the fifth patient in the order of succession. • 420 CHOLERA —[EPIDEMIC] Many other examples of transmission through families have occurred, but few so striking as this. We are disposed to attribute to contagion its full share in the production of such cases, aided by the circumstances of night-watching, neglect of order and cleanliness, &c, which are accompani- ments of sickness in the dwellings of the poor ; but we must remark that cases have fallen under . our observation and come to our knowledge, which | show a proneness to the disease in certain fami- lies, independent of reception from a contagious source. The following is an example of this kind. A respectable female, living in the village of Jes- mond Vale, where the disease did not exist, and who had had no intercourse with the sick, receiv- ed a letter announcing that a sister, whom she had not visited during her illness, and who resided at Hartley a distance of nine miles, had died of the complaint. She sickened in an hour from the receipt of the intelligence, and died in thirteen ] hours from the commencement of the attack.* j The following propositions appear to be reason- able corollaries from the facts presented by this extensive and intricate subject 1. Epidemic choleric fever originated in a cer- tain district under peculiar atmospheric circum- stances ; but these circumstances having previous- ly occurred in the same district without the pro- duction of a disease identically the same, we must regard its terrestrial or atmospheric cause unas- certained. 2. On many subsequent occasions there have been marks of its commencement and gradual rise in other districts, which show that, in their soil or atmosphere, there has been a tendency to the pro- duction of the disease from causes equally unas- certained as those which first originated it, and in such districts it has ultimately displayed itself. 3. It has thus appeared to arise in various dis- i tricts not by any means always continuous with i those previously contaminated, but often situated j in some general direction with regard to them, declining in one district as it arises in another, and thus appearing to move in a succession of local epidemic visitations. 4. Within the district which it occupies it pos- sesses a contagious property, or, in other words, those individuals who have intercourse with the sick, especially in a locally impure atmosphere, are attacked in a greater proportion than other members of the community; and it is probable that this same contagious property may be the means of diffusing it through a district disposed to the production of the disease, earlier than it might have arisen spontaneously there, or of ex- citing it in a district in which, notwithstanding a degree of predisposition, epidemic choleric fever might not have arisen spontaneously ; but facts which we have mentioned tend to render it ques- tionable whether it can be thus transferred to dis- tricts unpredisposed to receive or engender it. 5. Within the district where it prevails, ordi- nary endemial causes mingle their agency with that of the general cause of the disease, and the malady is found to vary in prevalence and inten- sity in different portions of the same district: thus the disorder is found to assail more individuals, * Related to the writer by Mr. Greenhow, surgeon, of Newcastle, who attended the case. I and to be more destructive in parts which are | dirty, and in those placed low or near the banks of a river, than in portions of the district differ- ently situated. The effect of these endemial in- fluences is illustrated by the progress of the dis- ease in the town of Sunderland, and by the rav- ages it has committed in the village of Newburn. The latter place is built along the margin of the river Tyne, and between it and the river there intervenes only a bank, formed of a mixture of mud and sand, partially covered at high-water; whilst a shallow stream of water flows through the village. Here, although the disease has not ceased, three hundred and twenty persons have been attacked, and fifty-five have perished, out of a population of five hundred and fifty. 6. The character of the disease varies consid- erably in the different districts which it invades. Thus we had occasion to observe that in a min- ing population dispersed over an extensive tract of country, the township of Hetton, the disease was attended with less collapse than in the lanes and alleys of a populous commercial town, and the mortality was consequently much less; for we cannot too strongly repeat what we have al- ready remarked, that the collapse is the measure of the danger. These observations are made with no view of depreciating the medical practice adopt- ed in that district, which was extremely skilful and prompt, and even, with due allowance for the difference of the character of the disease, very successful. It should be remarked, moreover, that extremely collapsed were intermingled with the milder cases, but in proportions the very re- verse of those we had observed elsewhere. In certain districts in Northumberland, we have rea- son to know the disease resembled, in its general character, that which prevailed at Hetton; but among some other mining communities the ex- tremely collapsed has been the common form of disease. We have remarked, too, that whilst in some situations the cases have, almost without exception, commenced with diarrhoea, in others the proportion of instances in which this has con- stituted the initiatory symptom has been smaller. This difference in the form of choleric fever in different local epidemic visitations, the cases oc- curring in any given district possessing a general correspondence in character, and being distin- guished from those which occurred elsewhere, was observed in India by Mr. Scott; and it appears to us that this circumstance, coupled with the trans- mutation of the disease more and more into a febrile form as it has approached more northern climes, displays a deviation from that sameness of character observed in diseases engendered exclu- sively by human contagion. It will hardly be expected that we should leave entirely untouched the question, whether the dis- ease originated spontaneously in Sunderland, or was introduced from abroad; but the extent to which we have already pursued this intricate por- tion of our subject forbids our discussing it at any considerable length. Those who reason from the postulate that the disease is diffused only by hu- man contagion will of course decide for importa- tion ; but others will very reasonably expect that j before this be admitted, it should be proved by the [ same positive evidence that would be required to • CHOLERA —[EPIDEMIC] 421 substantiate any other fact of importance. Any tiling approaching to this, or even any considera- ble probability of such an occurrence, we have been unable to discover ; and we cannot but agree with Dr. Ogden, that, whatever were the facilities for the importation of cholera here, they were much greater in other places ; and that if it has been imported, so far from following the great routes of human intercourse, it has chosen one of the least frequented paths, (See Medical Ga- zette for January 21, 1832.) [See on all this sub- ject the writer's Practice of Medicine, 2d edit. p. 138.] The predisposing causes of the disease, and the means to be adopted for preventintr its diffusion, have been published to the world in such multi- tudinous documents, that we consider it unneces- sary to occupy our pages with remarks on sub- jects now so familiar. [After the prevalence of cholera in England, Dr. Prout (Bridgewater Treatise, Amer. edit, p. 197 : Philad. 1834,) observed an absence of the common lateritious sediments in the urine; and about the time the disease first made its appear- ance, he noticed a positive increase in the weight of the air, similar to what might be supposed to be produced by the diffusion of a heavy gaseous principle through the lower regions of the atmo- sphere. Hence he concluded, that the cause of cholera and of the urinary peculiarity was a poi- sonous body analogous to malaria, whose high specific gravity, and feeble diffusive powers, kept it near the earth's surface, along which it insen- sibly crept, especially in low and damp situations. He very properly, however, does not lay much stress on this conclusion. During the prevalence of the above-mentioned state of the urine, he like- wise noticed, in almost every individual, an unu- sually acid state of the saliva, and of the cutane- ous exhalations; and about the time the cholera prevailed, and a little afterwards, he saw more cases of oxalate of lime renal calculi, and of for- midable hemorrhage from the kidneys, &c, than he had ever previously seen during the long peri- od that urinary diseases had occupied his atten- tion. As the cholera disappeared, these pheno- mena gradually subsided. The epidemic at Naples was complicated by a verminous constitution of the most singular kind that has ever been recorded. This verminous epidemic was not, however, confined to those who died of cholera, or who were affected with symp- toms of it, but occurred in all the inhabitants of the country; and it is asserted that the most con- stant morbid appearances, observed in cholera, such as injection of the digestive mucous membrane, development of the mucous follicles, the presence of an unusual kind of mucus, and of tricocepha- lous worms, with change in the character of the blood, were equally met with in those who died, during the epidemic, of other diseases than the cholera. (M. Thibault, cited in Amer. Med. In- telligencer, Feb. 15, 1838.)] Treatment.—Previously to entering on this very important subject, we think it advisable to endeavour to correct the misconception which ap- pears to prevail very generally among members of the profession, who have not as yet witnessed the disease, that some one specific remedy, or, at 2l ! least, plan of treatment, must be sought for, and when discovered invariably adopted. The import- ■ ance very properly attached by all writers to col- i lapse as a feature of the malady, and their candid avowal of the difficulty they have encountered in combating it, is the explanation of the fact that I medical men who are practically unacquainted | with epidemic choleric fever, have taken a view l of its treatment which in the case of almost any other disease they would have repudiated as un- scientific. We know no condition more hopeless than that of extreme collapse in the disease :—so hopeless, indeed, is it, that often have we ques- tioned, in watching a patient in this state, whe- ther our art at present possesses or is likely to pos- sess any resources against it, or, in seeing him emerge from it, and he has sometimes done so most unexpectedly, whether the remedies employ- ed, or some hidden power of the constitution, had been instrumental in effecting re-action. But it should be remarked that only in a proportion of cases—a proportion varying, as we have already observed, in different localities, and in the same locality at different periods of the epidemic—does this extreme collapse occur; and that even in cases of which the natural tendency is to pass into this deplorable condition, much may be done 1 by early treatment for its prevention. These con- siderations should teach physicians and patients that safety is to be found only in the early admin- istration of remedies; and the former, when brought into contact with the disease, will soon discover that success in its treatment must result, as in the treatment of other fevers, from adapting his remedies to the varying circumstances of indi- vidual cases and of the different stages of the same case, rather than from the trial of specifics for one portion only of an extensive series of changes:—that his practice, in short, to be suc- cessful, must be rational, not empirical. In the observations we have to make on the treatment, we shall follow the natural subdivisions adopted in describing the disease. 1. Treatment of the Incipient Stage.— We have adverted to two forms which this stage assumes. In the one, there is some general un- easiness, nausea, and vertigo: in the other these affections may coexist with diarrhoea, but the fat- ter is frequently present without the former being discernible. The first of these forms, in which it may be remarked that medical aid is rarely re- quested, requires that the stomach should be un- loaded by an emetic, and a table-spoonful of good mustard constitutes a very efficient one; a few ounces of blood should be drawn from a vein ; a laxative of calomel and rhubarb administered ; and the patient restricted to a diluent diet and kept within doors and warm. The treatment of the diarrhoeal form, to which circumstances wit- nessed by us lead us to attach considerable im- portance, must be noticed more at length. It was mentioned that, in this diarrhoeal form of the incipient stage, the evacuations are at first found to be feccal and bilious; but at the time medical aid is summoned, they have generally as- sumed the serous character which they bear in the choleric stage. A state of the system resem- bling, in some degree, collapse, it was observed, coincided with this condition of the alvine dis- «. 422 CHOLERA —[EPIDEMIC] charges. In this state it was found very advan- tageous to give a dose of calomel, conjoined with a proportion of opium and some aromatic,* and in twelve or fourteen hours afterwards a dose of castor oil. On first visiting such a patient, a large blister was generally applied to the abdomen, in the cases under our care; warmth was enjoined, —indeed where compliance with our wishes could be enforced, the patient was confined to bed,— and it was directed that the diet should be diluent. The subsequent treatment consisted in the em- ployment of smaller doses of calomel and opium for one or two successive nights, and a second dose of oleum ricini was sometimes administered. In certain localities the writer has found the constitutional state accompanying this stage of the disease to be one of marked excitement rather than of feebleness and collapse, and some points of the abdomen have been painful on pressure. In 6uch cases one general bleeding or the very libe- ral application of leeches to the abdomen, has pre- ceded the employment of other remedies. In other respects the same treatment has been found suc- cessful as that adopted in the preceding form, ex- cepting that no stimulating ingredient was mixed with the calomel and opium.-j- Under these plans of treatment we have the satisfaction to state that, in every case which has fallen under our immediate observation, the dis- charges have resumed their natural bilious appear- ance, and the diarrhoea has been finally arrested without the supervention of a cold stage, and, con- sequently, of fever, though the disease had oc- curred in various instances in persons who had been in incessant attendance on those ill of the feverish stage, and though in all cases it bore the characteristic marks of what we may term choleric diarrhoea. It should be remarked, how- ever, that the choleric stage has supervened, as we have been informed, on diarrhoea which had been skilfully treated ; but our inquiries have uniformly convinced us that in such cases medi- cal aid had not been summoned till the diarrhoea had existed some rime, and the subsequent stage was closely impending. 2. Treatment of the Cold or Choleric Stage.—In order that we may be distinctly un- derstood in our observations on the mode of con- ducting this very important stage, it is necessary that we should adhere to its subdivision into two periods.^ * The following is the formula we have usually em- ployed. R Hydrargyri chlorid. mit. gr. viii. vel. x. Opis, gr. ii. Pulveris capsici, gr. i ss. Coiifecticniis roste, q.ss. ut fiat bolus, statim su- mendus. t We think it proper to remark, as probably the reader will perceive Hie discrepancy, that this excited state of the system was net enumerated among the symptoms of the incipient stage of the disease in our description of epidemic choleric fever. In extenuation of this omis- wion, and, perhaps of certain deviations from strict order tltnt m.iv be discernible, it should lie mentioned that the composition of this article and our acquaintance with the disease, in various localities, have been simultane- ously in progress, and we have deemed it better to sac- rifice some degree of regularity than to withhold from the reader information which may speedily prove va- luable. J The credit of this subdivision belongs originally to Mr. Kennedy. Experience in the disease having con- vinced us of its practical importance, we have adopted it in this article. The first period is certainly that in which alone our most powerful means of arresting mor- bid actions can be employed with a considerable prospect of success. It may be considered an axiom in medicine, that fevers, to be successfully, must be early treated, and the rule has a power- ful application to a fever so rapid in its course as that under consideration. But there are many obstacles to ite being generally acted upon amid a town population ; and one considerable obsta- cle, we apprehend, will every where be found in that self-deception which seems to lie quite a fea- ture of the disease. We have met with persons to whom, fiom their peculiar situation, all the symptoms of this fever were as familiarly known as to medical men, yet when they were attacked with it, they did not or would not recognise it; and one such individual actually walked out with the disease upon him, and failed to send for assist- ance till eight hours after its invasion, though it was so severe as to destroy him in twelve. So strong is this tendency to self-deception regarding the nature of the disease when the choleric stage actually occurs, that wherever choleric fever pre- vails, strong appeals should be made to the pub- lic on the necessity of early treatment of this stage, as well as of due care of that which gene- rally precedes it. The first remedy to be considered is bloodletting, and we shall endeavour to point out the circum- stances which, so far as our observations extend, indicate, and those which forbid its employment. Its safe administration should be early, not ac- cording to mere time only, but with respect like- wise to the rapidity of the disease, for one case will have made as considerable a progress towards actual collapse in two hours as another will have done in ten ; and we should regard a considerable degree of collapse, indicated by feebleness or arrest of the circulation, and perceptible in the intervals of pain and spasm, (for when these occur, the pulse often sinks instantly, though only a second before it had been beating with considerable vigour,§) as an imperative reason for abstaining from drawing blood. But if we find the tempe- rature not below or but little below the healthy standard, a pulse of tolerable force, and strong spasms recurring at short intervals, provided col- lapse have not jjreceded this favourable condition, we should at once open a vein, and not lose an opportunity, which will never be restored, of pro- bably preventing extreme collapse, and either its I immediate fatality, or its more remote but scarcely i less fearful evils. But should this condition, with respect to circulation and temperature, have suc- ceeded to collapse, either spontaneously or by the administration of remedies, our experience would dictate that bloodletting should be carefully ab- stained from, as we have seen great injury pro- duced under such circumstances by its employ- ment ; cases having fallen under our notice in which the loss of three or four ounces of blood has destroyed the fruits of two or three hours' assidu- ous labour. The difference in the effect of blood- letting on conditions apparently very analogous, but differing in the periods from the commence- ment of the attack at which they manifest them- § Query—Doe* this sudden and momentary arrest of the circulation arise from spasm of the heart 1 CHOLERA—[EPIDEMIC] 423 selves, cannot be too strongly impressed on the reader's attention. Perhaps the only difference in external character which can be discovered be- tween the two states will be the existence of spasms of considerable strength in the early pe- riod, whilst in that more advanced they have nearly, if not altogether, ceased; but in the one case bloodletting breaks the morbid catenations, and prevents collapse and congestion ; in the other it lowers the vital energies which are freeing themselves from a state of oppression. But again, in a more advanced stage, when the constitution is no longer balancing between collapse and fever, and the latter may be considered as established, bleeding is a suitable remedy, if the state of the circulation and the general condition of the pa- tient render it admissible. Thus, then, there are three periods of the disease at which, according to our experience, bloodletting may be employed: occasionally in the incipient stage, as has already been stated ; in the early part of the first period of the cold stage ; and at the commencement of the feverish stage, under circumstances to be sub- sequently mentioned. We have been explicit on this head perhaps to prolixity, because we found great discrepancy in the testimony of various Indian and continental authorities regarding it; and in the early part of our experience of the disease, the selection of the appropriate time for bleeding, and the circum- stances which indicated or forbade it, constituted the greatest difficulty we had to encounter. The measure to be adopted next in succession to bloodletting will depend on the condition of the patient If in a short time after bleeding we find a circulation of tolerable force, without much tendency to general or partial deficiency of heat, and if at the same time there be pain in the epi- gastrium increased on pressure, a very common -accompaniment of cases in which the tendency to collapse is least conspicuous, a large blister or sinapism to the abdomen, and a dose of calomel and opium, in the proportion of from eight to twelve grains of the former to one and a-half or two of the latter, will be suitable remedies.— Should the circulation, on the other hand, be fee- ble, with general or partial deficiency of warmth, we should endeavour to rouse the system by full vomiting, and powdered mustard is a very proper means of accomplishing the object. Half an ounce of this substance, suspended in half an ordinary tumbler of warm water, may be considered a me- dium dose, and one which, in a great majority of instances, will act promptly and powerfully; but in a more advanced stage of the disease, when the collapse has been extreme, a whole ounce has been required to produce the full effect* After full vomiting, sinapisms may be applied to the abdo- men and along the spine; whilst the warmth of the patient is supported by bottles of hot water wrapped in flannel, bags of hot oats, and other familiar methods of applying dry heat, directed to the extremities or other points of which the tem- perature seems deficient. Frictions of the parts * It may save the reader some trouble to inform him, that un ordinary table-epoon, un heaped, contains half nn ounce of mustard; and that the mustard sold in the shops under the name of Durham inustard, which is of a uniform bright yellow colour, is the most pungent and I'fficacious. affected with spasm will at the same time be pro- bably required, and should be performed under the bed-clothes. We have not found any beneficial effect, in relieving the spasms, from oil of turpen- tine or other stimulating embrocations; the cold- ness produced by their evaporation probably more than compensating for any benefit they are in other respects calculated to effect A bolus of calomel, capsicum, and opium, the latter not in a proportion exceeding a grain and a-half or two grains, may- be administered as soon as the vomiting from the mustard has totally ceased. The quality of the liquid given at this period ought to depend on the condition of the patient: if, for instance, the ten- dency to collapse be considerable, a little weak brandy and water should be given at short inter- vals ; but, should the circulation be tolerably vigorous, and the temperature good, simple dilu- ents, such as toast and water, constitute the most suitable beverage. Should the patient be in a state of considerable collapse, whether consequent on neglect of the earlier stage, or occurring, which will occasionally prove to be the case, in spite of the most diligent attention to it, bloodletting should not form part of the remedial agents selected. If the tempera- ture be in any considerable degree below the healthy standard, with the hands cooling rapidly on exposure to the air; the pulse at the wrist either very feeble or totally suspended; the breath and tongue cool; the surface shrunk and pallid, or in certain parts livid ; the vomiting and spasms diminishing in their intensity, or totally ceased ;— at whatever period from the commencement of the diseace this state of things may exist, bleeding should be abstained from. It will be advisable to endeavour to rouse the system by full vomiting ; and half an ounce of mustard, or, if the attendant prefer another mode of accomplishing the object, two table-spoonfuls of common salt, a scruple of sulphate of zinc, or half a drachm of ipecacuanha with a small proportion of brandy may be admin- istered. Should the emetic selected fail to produce its effect in a quarter of an hour, it ought to be repeated ; or should the circumstances of the case lead the attendant to suppose that the sensibility of the stomach is very low, a larger dose of the emetic drug may be administered: we recollect having produced full vomiting by an ounce of mustard in a case of extreme collapse, in which two smaller doses had been administered succes- sively without effect. Simultaneously with the ex- hibition of the emetic, dry heat should be applied by some of the methods already mentioned, or by that very convenient and simple apparatus, the hot air-bath. Various internal medicines of the stimulating class have been recommended for this state. Those of which we have been led to form the most favourable opinion are mustard, carbonate of ammonia, and oil of turpentine. The first named substance we have not unfrequently administered in doses of a drachm, (a tea-spoonful unheaped,) at irrtervals of an hour or an hour and a half, ap- parently^ with the effect of giving additional vigour to the pulse, which had perhaps been re- stored by the vomiting ; of producing bilious dis- charges from the bowels; of restoring the urinary secretion, and aiding the system in. die transition 424 CHOLERA —[EPIDEMIC] into the febrile stage. If the carbonate of ammo- nia be the stimulant employed, a convenient mode of giving it is in doses of five grains every hour, with carbonate of magnesia, which makes it more easily retained should the stomach still retain its irritability. Should oleum terebinthinse be select- ed, doses of two drachms may be given every second hour. Whatever stimulant medicine be employed, we should advise that calomel in doses of five or six grains, repeated at intervals of three or four hours, should be given at the same time, with the view of aiding the restoration of secre- tion ; and, with the intention of at once rousing the system and lessening the irritability of the sto- mach, that a large sinapism should be applied to the abdomen, and another along the course of the spine. Various stimulating nostrums, if applicable to any, certainly only to this period of the fever, have been bruited forth to the world as specifics for the disease. In many of these we are of course inexperienced, and of all we are convinced the powers have been overrated, in some instances from partial and mistaken views of the malady, and in others from less pardonable reasons. It will not be deemed necessary that we should pass them all in review; but of certain remedies which have been proposed for collapse, the professional reader will require some notice. The inhalation of oxygen gas has been sug- gested from many quarters; and in some cases in which it has been tried here an instantaneous amelioration has been manifest, the pulse having become more vigorous, the lips florid, and the pa- tient having experienced relief from precordial oppression and other distressful feelings, to an extent and with a promptitude not afforded by any other measure. But the experience of medical observers in general has led them to conclude that this effect is very transitory; and some are of opinion that they have witnessed an increase of the collapse after the temporary excitement, as if the vital power, instead of being permanently increased by the measure, had been expended in a momentary flash. Of some gentlemen, how- ever, the opinion regarding it is more favourable. Our own opinion is, that inspired for a few seconds in single bladders, no great benefit is likely to accrue from it; but we should speak less positively of the effect of an atmosphere of diluted oxygen breathed for a considerable period. The tobacco enema has been suggested by Mr. Baird of Newcastle, and, as he assures us, em- ployed with considerable success. We acknow- ledge that a priori reasoning would rather have led us from this remedy than suggested it to us ; but knowing the fallacy of such reasoning in medicine, we are not disposed to treat with neglect, still less with contempt, a measure of the bene- ficial effect of which a gentleman of talent and character adduces several examples. It was pro- posed after the disappearance of the epidemic from Sunderland, and we have no experience of it; but we would recommend that it should be tried in a case to the successful treatment of which other measures seemed inadequate, the practitioner being governed, as to its subsequent employment or rejection, by its effect. Two remedies have also been mentioned to us by an individual of talent, and of great experience in the epidemic, Mr. John Fyfe, of Newcastle: we shall, with his permission, make the readei acquainted with them. One is the employment, in the period of extreme collapse, of an enema, consisting of two pints of warm water, from four to eight ounces of brandy, and from one drachm to two drachms of laudanum or Battley's sedative liquor. This, he assures us, has the happiest effect, in abridging that stage of the disease on the intensity and duration of which so much of the danger depends. The other is an enema contain- ing a drachm of powdered mustard, which he has found to be very speedily instrumental in restoring the urinary secretion. This accords with out experience, as already stated, of the efficacy of this substance given by the mouth, in accomplish ing the same object and the restoration of the secretions generally. W'eak brandy and water may be given occa- sionally during the collapse; and we have ob- served no injurious effect in this or any stage of the disease from the ordinary diluents taken in moderate quantities. 3. Treatment of the Excited or Febrile Stage.__The treatment to be now pursued will not require such lengthened discussion as that of the preceding stages, which may be considered as more exclusively belonging to this disease; for recognised principles, applicable to the treatment of pyrexia in general, must be our guides in con- ducting this fever. The fever constituting this stage, be it in es- sence what it may, has inflammation accompany- ing it, of which the principal sites are the brain and the lining of the digestive canal, and to the subduing of these, by such measures as the state of the system admits, our attention should be carefully directed. A form of fever has been described as super- vening on an extreme and long-continued collapse in the cold stage, and in which fever it was men- tioned that the vascular action was low and feeble, the temperature of the surface under the healthy standard, and the distribution of warmth very partial. In this low form of disease we have not ventured on general bloodletting ; local bleeding from the temples has been freely performed, and occasionally too from the integuments of the ab- domen, when there were any indications of in- flammatory affection of the digestive canal; but the great degree of intellectual torpor and insensi- bility which attends these extreme cases renders the discovery of such an affection extremely dif- ficult. Blistering the nape of the neck, and shaving the head so as to permit the application of cold, will be found very suitable measures. A degree of irritability of stomach, with occasional vomiting, is a very frequent accompaniment of such a case for the first two or three days; and under such circumstances leeches and subse- quently a blister to the epigastrium have been resorted to with benefit Of internal remedies, that on which most re- liance is to be placed is calomel, from its effects on the secretions, particularly of the intestinal canal, and from its facilitating the action of the laxatives which the state of the brain renders it advisable to administer. If two grains of calomel CHOLERA —[EPIDEMIC] 425 are given at intervals of three or four hours, an ' occasional gentle laxative, such as castor oil or i calcined magnesia, will generally produce two or | three bilious discharges from the bowels. Simul- taneously with the administration of these reme- j dies, the imperfect developement of heat and its partial distribution require attention. The patient should be placed near a stove or in some warm situation, and bottles of hot water, or hot flannels, should be applied to the feet, or other parts which are chilled. Even whilst endeavouring, by local depletion, to relieve partial determinations of blood, the general state of the system has been such as to require a little stimulus, and wine and water has been given, especially at an advanced stage of the disease, and occasionally medicinal stimulants, such as carbonate of ammonia, cam- phor, and sometimes, as a tonic, sulphate of qui- nine ; but we cannot say that much benefit has resulted from the latter class of agents. Such is the treatment we have generally adopted in that form of the febrile stage which is dis- tinguishable from any fever we have been in the habit of observing here or elsewhere. The more excited form admits of one general bleeding with advantage, the amount of blood drawn being regulated by the degree of vascular action, of headach, of injection of the eyes, and various cir- cumstances which would influence our proceeding in any ordinary fever. Should the head, as it generally does, continue affected after the blood- letting, the application of leeches and cold should be resorted to, the former being repeated, if neces- sary, to such extent and at such intervals, as the degree of headach, intellectual torpor, and vascular excitement may seem to require. Laxative medi- cine should be administered; and the purpose is exceedingly well answered by calomel in doses of four or five grains nightly, and six drachms or an ounce of castor oil every morning. The diet un- der such circumstances should consist of the mildest and simplest diluents, such as would be demanded in any case of inflammatory fever: after the case has subsisted some days, a little wine and water may be given if exhaustion be manifest, but it should not be continued beyond the necessities of the case. Though we have seen few or no cases without a degree of cerebral affection, examples are met with in which the dis- order of the intestinal canal is more considerable than that of the brain. Diarrhoea, the discharges being deeply bilious; a red, glazed, and very dry tongue; some degree of fulness and tension of the abdomen, and of pain on pressure there; and scanty high-coloured urine, generally attend such cases. The general treatment of cases in which such an affection exists, must depend on the state of the system ; but the intestinal disorder demands the free application of leeches to the parietes of the abdomen, repeated according to circumstances, and the internal exhibition of mild mercurials, such as hydrargyrum cum creta, or blue pill, with a small quantity of opium. That kind of permanent fomentation which is afforded by hot poultices to the abdomen, after the application of leeches, has been found beneficial. The diet throughout a case in which this inflammation of the mucous lining of the intestinos exists, should be mild and demulcent In cases of this descrip- Vol. I. —54 3i* tion—indeed in the most excited as well as in the lowest forms of the disease in which the collapse of the cold seems prolonged through the febrile stage—it is advisable to counteract, by warmth to the extremities and other points, that tendency to irregular distribution of blood which forms so striking a feature of the disease. Cases are oc- casionally met with, so mild in all their stages, that the fever requires no.medical treatment but a few leeches to the head, a little laxative medi- cine, and abstemious diet for a few days. [The intense thirst of cholera must be satisfied by a liberal allowance of ice or of ice-cold water. They are most grateful, and tend to allay the irri- tability of the stomach. To arrest the diarrhoea in all stages, the acetate of lead was much employed in this country, and was highly extolled by many practitioners, as well as by Dr. Graves, of Dublin. In the writer's own observation it was not attended with any strik- ingly salutary effects. Strychnia was used en- dermically, and, it was affirmed, with advantage. It was, also, given internally to allay vomiting, and Dr. Ryan, somewhat hyperbolically we fear, states, that a twelfth of a grain, given in pill, and repeated a few times, has been frequently known to check a profuse diarrhoea with rice-water evacu- ations, and even when the extremities were blue, in cholera, (Ryan's Universal Pharmacopoeia, 3d edit, p. 336 : Lond. 1839.) The extensive loss of serum, and, consequent- ly, of the watery and saline parts of the blood, led to the administration of solutions of common salt and of the carbonate of soda internally, both by the mouth and in enema; but owing to the suspension of absorption, these substances rarely or never got into the blood-vessels. It was then proposed to inject them into the blood-vessels; yet although they became mixed with the blood, they could not remove the pathological cause that gave occasion to the profuse separation of its wa- tery and saline portions. Hence, they were not found to answer preconceived expectations.] Convalescence is in many cases tedious, the strength being slowly restored, and slight irre- gularities of diet sufficing to disorder the system, and even to produce relapse. For weeks after the fever we have found the patient still languid, I and exceedingly prone to irregular distribution of ! blood, especially to undue determination to the head, inducing headach (requiring the application of leeches) on any considerable exertion. To prevent such occurrences, we have found it advi- ! sable that the diet should consist, in the early ! period of convalescence, of a moderate quantity I of vegetable matter only, and that the transition to more abundant and substantial food should be very gradual ; in short, that convalescence from this disease should be conducted in the same manner as that from other fevers. We have stated that relapse may be produced by dietetic irregularities; and it is importaat to j observe that even the best directed treatment of J the incipient or diarrhoeal stage may fail in its ob- j ject, that of cutting short the disease, if such irre- gularities are indulged in. The relapses, properly ! so called, have occurred at an early period of con- i valescence; but we have witnessed one example, and that a very severe one, of the recurrence of 426 [CHOLERA INFANTUM.] epidemic choleric fever after an interval of two months from the preceding attack. This we were disposed to consider rather as an example of second invasion than one of relapse, though it is proper to remark that the patient had remained feeble from the period of the previous disease. No as- signable cause existed for the second attack. [During the prevalence of cholera, municipal regulations were made in many of the cities in regard to the articles of diet that might be allowed with safety, during the epidemic constitution.— Some of these were of the most whimsical kind, dependent probably, at times, on individual likes or dislikes, caprices or prejudices. Ripe fruits, and succulent vegetables, were generally pro- scribed : yet the fact, that in charitable institutions, where no such articles were permitted, cholera was most fatal; that the disease prevailed most fatally at Moscow, St. Petersburg and elsewhere, at seasons when ripe fruits and vegetables could not be procured ; and that where ripe fruits were freely allowed, as in London, at a later period of the epidemic, no inconvenience was found to re- sult from them, ought to have created well-founded doubts, whether the proscription were founded on accurate observation. (See the writer's Elements of Hygiene, p. 302: Philad. 1835 ; and his Prac- tice of Medicine, edit cit i. 147.)] Joseph Brown. [III. CHot.EnA Ixfanttjm.—This form of cho- lera, commonly known under- the name of sum- mer complaint, has been generally regarded as peculiar to the United States. As elsewhere re- marked, however, (Practice of Medicine, edit. cit i. 147,) it strikingly resembles the affection vulgarly called "waterygripes," in England. It does not appear to be known in Paris: (Barthez and Rilliet, Traite Clinique et Pratique des Ma- ladies des Enfants, i. 552: Paris, 1843.) It is one of the most fatal affections to which children are liable. In Philadelphia, during a period of fifteen years, from 1825 to 1839 inclusive, 3352 infants died of it—being almost 10 per cent, of the whole number of infants under five years of age who died during that period; and 4-5 per cent of the entire mortality of the city. (Condie, Practical Treatise on the Diseases of Children, p. 217 : Philad. 1844.) Diagnosis.—Cholera infantum commonly be- gins with diarrhoea, more or less profuse ; but at other times both vomiting and purging come on at first, without any premonitions ; or the infant may have suffered for a time under gastric or in- testinal derangement. The pulse is usually fre- quent and somewhat tense; and there are almost always manifest signs of febrile irritation. The discharges are, at first, extremely fluid and often frothy, sometimes tinging the cloths green, and at others leaving mucus upon them. In very se- vere cases the system becomes rapidly prostrated, and the child may die in the course of twenty- four hours; but more commonly the disease con- tinues for a few days before either the tendency to convalescence or to death is manifest As in the cholera morbus of the adult, there is often severe intestinal pain, which may be increased by pres- sure ; and, at times, the muscles of the abdomen and extremities contract spasmodically. The thirst is excessive, and the appetite gone or singularly capricious. If the disease be about to terminate unfavourably, emaciation makes frightful progress; the febrile irritation is constant and manifest; the child becomes restless and comatose, and gradually sinks—the fatal termination being, at times, pre- ceded by convulsions. Frequently, the evacuations exhibit the existence of great irritability of the digestive tube, the food passing rapidly through it without undergoing any change, and being squirt- ed out with great force. At other times, they have a putrid or cadaverous odour. In the more pro- tracted cases, these appearances are more frequently met with, along with aphtha? of the mouth, mc- teorism of the abdomen, and other signs of follicu- lar inflammation. At times, before death, a vesi- cular eruption appears extensively on the chest, which Dr. Dewees (Treatise on the Physical and Medical Treatment of Children?) considered to be invariably a fatal symptom ; but Dr. Condie (op. cit. p. 219,) states, that he has in many in- stances known the patient to recover even when this eruption has been the most extensive and distinct. The great indication of recovery is the appear- ance of feculent matter, and of the ordinary secre- tions in the evacuations. Causes.— Excessive heat is unquestionably concerned in the causation. It is, indeed, in the summer months that the disease prevails so fearfully and so fatally in our cities; yet some- thing more than heat is required to induce it extensively ; for, in country situations, it is com- paratively rare. Atmospheric vitiation must be combined with atmospheric heat, and hence it pre- vails in the most crowded alleys of cities. In cleanly and well-ventilated districts, and in large, airy apartments, deaths from it are uncommon; so that at times when the bills of mortality indi- cate the greatest amount of deaths, physicians who practise extensively in the better portions of cities may see but little of it (Practice of Medi- cine, i. 148.) Dr. Condie (op. c>t. p. 221,) states, that when it occurs in the country, it is almost exclusively in low, damp, and otherwise unhealthy situations; but such has not been the result of the author's experience. Age affords a predispo- sition. The common idea is, that children are more liable to it in the second summer than in the first; but this does not seem to be confirmed by statistical observations. From the official reports of deaths in Philadelphia and New York, it would appear that, in the former city, of 229 deaths as- signed to summer complaint, 142 occurred in chil- dren under one year of age ; 75 in those from one to two years; and 12 in those from two to five years. It rarely occurs in infants under three months of age. Under the predisposition induced by great at- mospheric heat and vitiation, it is clear that im- proper aliment may be an exciting cause ; hence, children brought up on spoon-meat suffer in greater numbers than those that are nourished at the breast In like manner, dentition may contribute to its production. Pathological Characters. — The mucous membrane of the bowels generally exhibits evi- dences of inflammation, especially of the follicles, which by some have been regarded as the primary [CHOLERA INFANTUM.] —CHOREA. 427 seat of the disease. When it has existed for any I time, increased redness, in points and patches, has been observed in different parts of the stomach and intestines; but attention has not generally been paid to distinguish whether these consist in simple hyperemia or in inflammation of the lining membrane. The follicles are very generally en- larged, inflamed, and occasionally ulcerated ; the enlargement, according to Dr. Horner, (Patholo- gical Anatomy, Philad. 1829,) often resembling a sprinkling of white sand upon the surface of the mucous membrane. Occasionally, considerable portions of the digestive tube are so much con- tracted as scarcely to admit a small-sized quill; at other times, portions of the mucous membrane of the stomach and intestines are greatly softened. The liver is almost always enlarged. This has likewise been regarded as the primary affection ; but it is more probably secondary. The encepha- lon, in nearly all cases, has been found in a state of hyperemia, and in long protracted cases serous effusions have been met with in the ventricles, and at the surface of that viscus. Treatment.—The general principles of man- agement do not differ materially from those laid down under enteritis of the mucous coat, and diarrhoea. The cases that occur in the airy parts of a town are usually managed with facility, and carried to a fortunate issue; whilst those in the narrow alleys of the worst parts too often resist every effort of the practitioner. It is all-important to remove the little sufferer from the air that has generated the disease, to another situation. This of itself is often enough to arrest the affection; but it may be necessary to combine with it a gen- tle laxative — as a small dose of calomel or of rhubarb and magnesia. Should the febrile action be considerable, it may be advisable to apply a few leeches to the epigastrium, more on account of the revulsion, than of benefit to be derived from loss of blood,—covering the abdomen after the leech-bites have ceased to bleed, with an emollient poultice. In other cases, especially where there is great irritability of stomach, stimulating cata- plasms or fomentations may be applied, and in pro- tracted cases a blister. Should the disease not yield to the above treatment, small doses of the mild chloride of mercury may be. given frequent- ly, to produce a new action, if the child be under two years of age, which, as has been seen, is usually the case. After this age, there is greater danger of inducing severe mercurial stomatitis.— Should signs of acidity exist, magnesia in the early period, and prepared chalk subsequently, may be useful adjuncts. Hence, the hydrargyrum cum creta" of the pharmacopoeias is a convenient preparation. Where irritability of the stomach is present, which is not relieved by external revel- Ients, injections of salt and water may be used in the way of revulsion ; or gentle excitants may be given internally, as a drop or two of oil of aniseed in sugared water, or five or six drops of sulphuric ether in the same vehicle. It need scarcely be said, that should irritation from teething exist, the gums should be freely di- vided, and should even the tooth not be set at liberty, the revulsion, thus induced, may prove salutary. The warm bath is beneficial in all periods of the disease. In the more protracted cases, astringents become necessary. The acetate of lead has been highly extolled by many. (Dr. H. Lindsly, Amer. Journ. of the Med. Sciences, xxiv. 311.) The oil of turpentine has been advised when there is flatulent distension of the stomach and bowels; and with the same view, a few drops of any of the essential oils may be administered. Great caution must, however, be had in the use of both excitants and astringents. During the convalescence any of the milder tonic infusions may be prescribed. Throughout the disease, care must be taken in regard to the diet; and, where practicable, the child should be mainly restricted to the mother's milk. Where this cannot be done, boiled milk and water, with any of the farinaceous preparations, as sago or arrowroot, may be used. By many, the infusion of benne-leaves or gum-water is given freely; but it may be questioned whether these mucilaginous substances are of much benefit;— they may tend to shield and soothe the part with which they come in contact, but they are difficult of digestion. The appetite is apt to be very ca- pricious—a great desire being occasionally shown i for salted meat, salt fish, butter, &c.; and it has been esteemed proper to gratify it occasionally to a certain extent. Doubtless, in many cases, no evil has resulted from such indulgence, but it must necessarily be hazardous. To allay the intense thirst, iced water may be allowed; or the infant may be permitted to suck ice contained in a piece of gauze. At all periods of the disease, one of the most important curative agencies is change of air. If the child be removed into the country, this is the best course ; but where this cannot be accom- plished, riding or carrying the child about in the open air is of essential service. In the way of prevention, removal during the summer heats to the country ; or, if compelled to remain in town, sleeping on a mattress, with the door and windows of the chamber open; the daily use of the tepid or cold bath ; exercise in the open air, and, if the child be weaned, well-regulated diet, with especial abstinence from unripe fruits and the succulent vegetable. The constant use of a flannel bandage, even through the heat of sum- ! mer, has appeared to the writer an important pro- phylactic. Robley Dunglison.] CHOREA.—The word chorea, as used by the ancients, signified a dance of many people to music, being derived from x°Pis' a band of singers and dancers. The origin of its application to nosology is involved in some obscurity. Syden- ham and other writers have treated of the disease under the name of chorea Sancti Vili, a desig- nation which has been very properly curtailed by Cullen and most subsequent authors. This latter appellation, we are told by Horstius, was acquired in consequence of some women of disordered minds and affected with a peculiar restlessness of their bodies, repairing, once a year, to the chapel of St. Vitus, near Ulm, and continuing there, night and day, leaping and dancing, until they were completely exhausted. By this means they were said to be cured for a time ; but at the ex- piration of a year the disease returned, and was again removed in the same manner. The malady, 428 CHOREA. however, which is commonly known by the name of chorea, is very different in its symptoms from the original disease so called, although they have been classed together, and sometimes supposed to arise from the same causes. In this, as in many other instances, it is diffi- cult to determine by what name the disease was known to ancient authors. Probably it was for the most part confounded with other convulsive diseases. Even Cullen, in the first edition of his Nosology, included it in the general term con- vulsio, from which, however, he afterwards saw reason to separate it. Galen appears to describe it with tolerable accuracy under the name of scelotyrbe, which means " an agitation of the leg." " It is a species of atony or paralysis," says he, " in which a man is incapable of walking straight on, and is turned round to the left when the right leg is put forward, and to the right when the left is put forward alternately. Sometimes he is incapable of raising the foot, and hence drags it awkwardly, as those who are climbing up steep cliffs." It is also placed as a species of scelotyrbe in the nosological systems of Sauvages and Sagar. Dr. Mason Good, in his arrangement, ranks it as a species of synclonus, the term by which he ex- presses " a multiplied, conjunctive, or compound agitation of the muscles." Cullen defines chorea in the following man- ner: " Convulsive motions, partly voluntary, and for the most part of one side, attacking either sex before puberty, generally between the tenth and fourteenth year; the motions of the hands and arms resembling the gesticulations of players; one foot being rather dragged than lifted in walking." Sydenham has described it in a very graphic and accurate manner, as being " a species of convul- sion which for the most part attacks boys or girls, from the tenth year to puberty. It first announ- ces itself by a kind of halting, or rather insta- bility, of one leg, which the patient drags after him, as idiots do. Afterwards it shows itself in the hand of the same side, which, when applied to the chest, or any other part of his body, cannot be retained in the same situation by the patient even for a moment, but is twisted about from one place to another, however much he strive to pre- vent it. If a full vessel be given him to drink from, before he can bring it to his mouth he ex- hibits a thousand gesticulations, like a mounte- bank ; for as he cannot carry the cup in a straight line to his lips, the hand being diverted by the spasm, he tips it from side to side for some time, until at length, by good fortune, approaching it nearer to his lips, he jerks the liquor suddenly into his mouth and drinks it with eagerness, as if the poor creature were merely performing a feat to excite the laughter of by-standers." (Syden- hami Opera, p. 468 : Lipsia\ 1827.) Dr. Hamil- ton, in his Treatise on Purgative Medicines,— after stating that the disease chiefly occurs from the eighth to the fourteenth year, in those who are of a weak constitution, natural or acquired; that it is generally preceded by a variable appetite, loss of vivacity, a tumid belly, and constipated bowels; and that the convulsive motions are ushered in by slight, irregular, involuntary twitch- ings, particularly of the muscles of the face,— presents us with the following description of the disease in its more aggravated shape: "These convulsive motions vary. The muscles of the extremities and of the face, those moving the lower jaw, the head, and the trunk of the body, are at different times and in different instances affected by it. In this state the patient does not walk steadily ; his gait resembles a jumping or starting; he sometimes cannot walk at all, and seems palsied ; he cannot perform the common and necessary motions with the affected arms. This convulsive motion is more or less violent, and is constant, except during sleep, when, in most instances, it ceases altogether. Although different muscles are sometimes successively con- vulsed, yet in general the muscles affected in the early part of the disease remain so during the course of it Articulation is now impeded, and is frequently completely suspended. Deglutition is also occasionally performed with difficulty. The eye loses its lustre and intelligence; the countenance is pale and expressive of vacancy and languor. These circumstances give the patient a fatuous appearance. Indeed, there is every reason to believe, that, when the complaint has subsisted for some time, fatuity to a certain extent interrupts the exercise of the mental facul- ties. Fever, such as arises in marasmus, is not a necessary attendant on chorea; nevertheless in the advanced period of the disease, flaccidity and wasting of the muscular flesh take place, the con- sequence of constant irritation, of abating appe- tite, and impaired digestion, the common attend- ants of protracted chorea." (Observations on the Utility of Purgative Medicines, chap. iii. p. 69, et seq.) The sensations are little, if at all, dis- turbed ; but in extreme cases there are hardly any of the voluntary muscles exempted from the spas- modic affection. The tongue is occasionally pro- truded, the mouth drivels, and the eye itself is twisted in various directions. Not unfrequently there is some pain of the head, for the most part I in the occipital region; vertigo; and imperfect vision. The patient is often fretful, and liable to the same varied, desultory, and causeless motions I which occur in hysteria. The disease is apt to I recur more than once in the same individual. Occasionally it has passed into hemiplegia or I epilepsy, and instances are recorded of its proving j fatal in that manner, or by exhaustion. Dr. | Elliotson mentions, that when a student, he saw a young woman, labouring under the disease, die I apoplectic. (Med. Chir. Trans, vol. xiii. p. 252.) j In most cases, however, it terminates favourably, | after a duration of variable length. In eighty- j four cases occurring at the Norwich Hospital, Dr. | Reeves states that the shortest period of medical | treatment, was two weeks; the longest eight months; and the common average, seven weeks. ! (Edinb. Med. and Surg. Journ. vol. viii. p. 314.) j Although the disease commonly occurs between : the ages of eight and fifteen, it is met with as i early as the fifth or sixth, and, on the other hand, even in mature years. Dr. Powell mentions an | instance of it in a lady of seventy, (Med. Trans. vol. v.) ; and Dr. Bouteille relates one which oc- curred in a lady eighty years old, after hemiplegia. (New Med. and Phys. Journ. vol. iii. p. 175: London. 1812.) It oftener attacks girls than boys. Heberden found it to do so in the propor- CHOREA. tion of three to one, and Dr. Elliotson states that his experience presents nearly the same result (Med. Gazette, vol. vii. p. 652.) Of the eighty- four cases reported by Dr. Reeves, fifty-seven were females, and twenty-seven males. Of seventy- two occurring in Dr. Manson's practice, at Not- tingham, fifty-three were females, nineteen males. (Medical Researches on the Effects of Iodine, p. 230.) Of eighteen cases in the Hampshire County Hospital, during the last ten years, six were boys and the rest girls. Occasionally, chorea is complicated with hyste- ria or other disorders, and thus a confusion of symptoms occurs. In some cases the disease is of so partial a description as to continue through life without any injurious effects to the general health, or even any serious inconvenience. Dr. Mason Good mentions the case of a barrister of great reputation, in whom the only symptom was an occasional awkward snatching of the arms and neck; and another of a person who, though a dis- tinguished vocal and instrumental musician, had extraordinary gesticulations of the face and cur- vetings of the neck and head. Most practitioners have doubtless witnessed similar instances. The characteristic signs of the ordinary disease are the permanency, the irregularity, and the partly voluntary nature of the motions. There are other diseases of clonic spasm, in which the motions are perhaps as unintermitting as in this, but they present a regular and unvarying appearance. On the other hand, spasms of an irregular description, but not continuing, are daily met with. In both these cases, however, the affection should be classed under the general term convulsion. The partial influence of the will over the muscular contractions is, for the most part, a circumstance which of itself distinguishes the ordinary chorea from every other spasmodic affection. It has, however, been customary to include under the same name some more rare diseases not always possessed of these characters; and the term seems to be somewhat loosely assigned to many abnor- mous affections of a spasmodic nature. We admit, indeed, that the very malady to which the name was originally given does not present the charac- teristic signs we have mentioned; and it might seem arbitrary to separate it entirely from that which has received the appellation, solely from somewhat resembling it in appearance. When it is considered, however, that there are no sufficient reasons for concluding that they are of similar origin, and that the disease to which the above characteristics do apply is of infinitely more fre- quent occurrence, and is at the same time univer- sally known by the name of chorea, we think it right, for the sake of avoiding confusion and error, to confine our attention at present to the latter. Afterwards we will subjoin some account of the original disease, and other affections which resem- ble it or have received the same appellation. Some of the German writers have distinguished the two diseases by calling one the German, or great St. Vitus's dance, the other the minor St. Vitus's dance, or chorea of England. If they are still to be included under the same genus, the difference of their character might be better expressed by styling the one intermittens, or periodica,- the other continua; the former methodica, the latter abnormis ; according as the circumstances above- mentioned shall, one or other of them, be consi- dered the most characteristic of the chorea com- monly met with in this country. Causes.—The ordinary chorea has been attri- buted to various causes. Sydenham ascribed it to a humour thrown upon the nerves. By very many authors it has been considered as a disease of general weakness of the constitution. And others there are who conceive it to arise from a partial and slow inflammation of the brain. With regard to Sydenham's hypothesis, it has followed the rest of the humoral theories, and does not now require notice. That the disease is always simply one of general debility, is a notion opposed by the benefit sometimes obtained from bleeding, the very uniform advantage arising from purgatives, and the occa- sional failure of tonic medicines, when uncom- bined with other remedies, in the treatment of the disease. Many circumstances, however, concur in showing that, though debility may not be the original cause of the disease, yet it is often the principal reason of its continuance when once established. On the other hand, the idea that it is in general an inflammatory affection of the brain, as Dr. Clutterbuck and others have supposed, is contravened by the experience of Sauvages, Cul- len, and many other practitioners, who have found bleeding very prejudicial in a great many cases. And although this was one of Sydenham's reme- dies at the beginning of the disease, he does not advise it to be repeated frequently; recommend- ing, however, the purgatives and tonics with which he accompanied it to be continued through the whole course of the complaint. (Op. cit. 470.) Whether, as Professor Gregory supposed, (Edin. Med. and Surg. Journ. vol. i. p. 33), the success of Sydenham's practice was entirely owing to the tonics, or whether it was attributable to the pur- gatives, or to both together, may possibly be a matter of dispute ; but we think there is not much reason to attribute it, in general or chiefly, to the venesection. Dr. Armstrong, who mentions a case in which the free use of the lancet was nearly fatal, states that he considers chorea to arise from irritation of the mucous membrane of the stomach and smaller intestines, accompanied with a torpor of the skin, liver, and colon. (Lancet, vol. viii. p. 70). Dr. Hamilton, sen. from extensive experience of the benefit derived from purgative medicines, and the general appearance of the alvine evacua- tions, considers the disease to arise from disordered bowels. It has, however, been suggested by Dr. Coxe, (Med. and Phys. Journ. vol. xviii. p. 223), Dr. Uwins, (Edin. Med. and Surg. Journ. vol. viii. p. 411), Dr. Manson, (Medical Researches, &c. p. 192), and others, that such torpor and derange- ment may be merely an effect of the disorder, or at most a simultaneous expression of disease. Cullen thought that the malady depended upon " a state of mobility" in the system, (Materia Medica, vol. ii. p. 112); and we are so far of opinion with him as to believe that chorea may be induced by any irritating cause operating upon a suiriciently ex- citable habit of body. The greater number of diseases arising before puberty are perhaps con- nected or complicated with intestinal irritation ; and chorea, among others, doubtless frequently proceeds from disordered alvine secretions, from 430 CHOREA. worms, from accumulated fasces, improper diet, &c. But it has also been occasioned by affections of the mind, such as fright* Dr. Reeves states that in the majority of cases the disease is attri- buted by the parents to this cause, (Edin. Med. and Surg. Journ. vol. viii. p. 315) ; and Mr. Bed- ingfield tells us, that of upwards of forty cases which occurred at the Bristol Infirmary, by far the greater number were induced by fright. (Com- pend. of Medical Practice, p. 52. London, 1816). It has also sometimes arisen from irritation.-(- It has been occasioned by a wound of the brain through the orbit, (Philosoph. Transact, vol. liii. 1763), and other injuries about the head. (Edin. Med. and SuTg. Journ. vol. viii. p. 406 ; vol. ix. p. 123. Med. and Phys. Journ. vol. xv. p. 127). A case, in which it was induced in a man twenty- three years of age by injury to the scapula, is related in the Medico-Chirurgical Review. (Vol. ii. p. 569. 1827). It has also been occasioned by teething, (Edin. Med. and Surg. Journ. vol. i. p. 32) ; by the deleterious influence of certain metals and their compounds; preparations of lead, for example, or of mercury, (De Haen, Rat. Med. part iii. p. 202. New York Med. and Surg. Register. 1818. Med. and Phys. Journ. vol. xlii. p. 160); by suppressing eruptions of the skin, (Darwin's Zoonomia, vol. iv. p. 290. Wendt, Nachricht von dem Krankeninstitut zu Erlaneen. 1783); and frequently by retarded or difficult menstruation. (Bedingfield's Compendium, &c. p. 52). [Age occasions a marked predisposition. The disease is one of childhood. Of 32,976 children, admitted into the Hopital des Enfans of Paris, during 10 years, only 189, according to M. Rufz, (Archives Generates de Medecine, iv. 239 : Paris, 1834), were affected with chorea ; so that it is not very common. In the composition of their chapter on this subject, MM. Barthez and Ril- liet (Traite Clinique et Pratique des Maladies des Enfans, ii. 294 : Paris, 1843), state that they had analyzed only nineteen cases, and some of these vfere communicated to them by other observers. In a recent clinical lecture on chorea, (Medical Examiner, Jan. 27, 1844), the writer stated that he had not seen, altogether, more perhaps than thirty well-marked cases. The ages, at which the disease prevails most, are from 6 to 11. Sex, also, affords a predisposition, according to all observers. Of 240 cases, recorded by M. Du- fosse, 79 were in boys, 161 in girls, (H. Bell, Art. Choree, in Diet, des Etudes Medicales, Paris, 1839); and of the 189 cases referred to above, 51 were males, and 138 females. From the cases that have been recorded by different practitioners, it has been calculated, that the proportion of females to males is nearly 3 to 1. (Practice of Medicine, 2d edit, ii. 240 : Philad. 1844.) In regard to constitution, great difference of sentiment has existed. Some—as the Franks— affirm, that it occurs chiefly in the scrofulous * StoU, Rat. Med. part iii. p. 405. Edin. Med. and Surg. Journ. vol. ix. p. 3f*2. Med. and Phys. .loom. vol. Iii. p. 2^2. Med. Chir. Transact, vol. x. p. 2-25. .Med. Gazette, vol. i. p. J 95. Malison's Medical Researches, p. l!)6. t Edin. Med. and Sure. .Tourn. vol. i. p. 31 ; vol. iii. p. 441; vol. xii. p. 401. See also Ilaygarth on Imagination »8 a Cause, and as a Cure of Disorders of the Body. evo. Bath, 1600. and the rickety; while others, as Dr. Elliotson, (Principles and Practice of Med., Amer. edit, by Dr. Stewardson, p. 624: Philad. 1844), M. Rufe, and MM. Barthez and Rilliet, state, that no con- stitutional difference is perceptible between those who are affected with chorea and those who are not. A like discrepancy exists in regard to the colour of the hair. MM. H. Bell, Rufz and Du- fosse say that the subjects are chiefly light-haired : whilst Dr. Watson (Lectures on the Principles and Practice of Physic, Amer. edit. p. 360; Philad. 1844) remarks, that the disease occurs much more frequently in children having dark hair and eyes. It would appear, also, that a pre- disposition to chorea may be transmitted from parent to child. (Elliotson, op. cit.) The disease may unquestionably be developed by imitation, and hence the necessity in boarding- schools of keeping the patients separated. (Andral, Pathologie interne.) It is proper, however, to remark, that M. Blache states, that in the large Hopital des Enfans, of Paris, he never saw it pro- duced in this manner. Dr. Bright has drawn attention to the connec- tion of chorea, in certain cases, with affections of the heart and pericardium; and Dr. Addison has noticed mitral bruit or other signs of morbid ac- tion of the mitral valves to be pretty uniformly present in chorea,—which he is rather inclined to consider an effect of the disease than a cause. (The author's Practice of Medicine, ii. 241.)] It is extremely probable that the convulsive motions may be continued, merely from habit a considerable time after the original cause is re- moved.^ Mr. Hunter, of Glasgow, conceives that although the motions are not at first dependent on any derangement of the brain or spinal cord, yet the irritation, which acts at first locally on the ■ nerves of the affected muscles, may spread till it affect the root of the nervous system itself; and in this way he would explain the continuance of the convulsive motions after the removal of the original cause, (Edin. Med. and Surg. Journ. vol. xxiii. p. 270.) May the morbid appearances, such as the following, which have been observed in some cases of chorea after death, be accounted for in this manner ? In two instances Dr. Willan found some ounces of serum in the ventricles of the brain, (Reports on the Diseases of London, p. 245.) Dr. Coxe, of Philadelphia, who conceives that chorea uniformly arises either from hydrocephalus or its forerunner, inflammation and turgescence of the blood-vessels, found, in a fatal case, the vessels turgid, and twelve ounces of serum in the ventricles, (Med. and Phys. Journ. vol. xiii. p. 405; vol. xviii. p. 221.) Dr. Patterson, of Londonderry, (who, in opposi- tion to Dr. Coxe's Views, and in accordance with Dr. Percival, of Manchester,—see Medical Tracts, vol. i. p. 125, 1791,—considers that in chorea, as in other convulsive diseases, hydrocephalus is foi the most part rather a result than the cause,§) has related a case in which he found the blood-vessels X " ftppe tamen malum consuetudine ingravescens le- vioribus chums excitatur, parum cnguitis, neque facile observances." Gregory, Conspectus Mudicin. Theoret. vol. i. p. 210. J This question is ably arjued between Drs Coxe and Patterson, in the 13th, 15lh, and lfctli vols, of the Med. I and Phys. Journal. CHOREA. 43 turgid, and traces of inflammation in the brain, a kind of serous diffusion over the convolutions, and three ounces of serum in the ventricles.* He also mentions a case in which the patient, after being cured of chorea, very soon fell a victim to hydrocephalus, (Med. and Phys. Journ. vol. xv. p. 127.) M. Serres states that in one case he found a fatty tumour resting on the tubercula quadrige- mina; in another, marks of considerable excite- ment, with bloody effusion at the base of these bodies; and in two others the whole of their sub- stance was inflamed, and the inflammation ex- tended to the roof of the fourth ventricle, (Lancet, vol. xiii. p. 133.) It appears also that he has, by experiments on living animals, found that injury of these parts is followed by motions similar to those of chorea. We are not aware that these experiments have been published in detail, and are therefore unable to estimate their accuracy or con- clusiveness. We would, however, express a doubt whether M. Serres's cases of chorea were of the ordinary species; and we think that the simple fact of their proving fatal, in some measure justi- fies us in this hesitation, especially when the vagueness with which the term has been often used is taken into consideration. We shall pre- sently remark on the probable origin of those more rare diseases which have been denominated chorea. In the mean time, we shall only mention that M. Serres admits that he has seen cases of chorea in which no injury in the brain could be discovered after death. In a fatal case of a some- what anomolous character, published by Dr. Haw- kins, there was no morbid appearance discovered within the cranium, but earthy concretions were found in the pancreas, omentum, and mesentery ; tubercles in the lungs ; and the uterus was large and vascular, with its lining membrane highly injected, (Med and Phys. Journ. vol. lvii. p. 240.) [The fact, that the disease generally termi- nates in perfect health, shows that the affection of the neurine is not serious, and classes the dis- ease amongst the neuroses. They who believe that the cerebellum is the regulator of the move- ments would necessarily place chorea in that part of the encephalon. Dr. Marshall Hall refers it, with convulsive movements in general, to his reflex system ;—in other words, to the true spinal marrow. The disease belongs, however, rather to a badly regulated volition, like that which ex- ists in stammering, which has, indeed, been called —not inappropriately—a " Saint Vitus's dance of the voice," and is, consequenty, encephalic rather than spinal. The disease is essentally a func- tional affection of the nervous centres, in the large majority of cases, but of what precise na- ture we know not,—except that, generally, signs of great nervous mobility and debility are present, and have to be energetically combated.] Treatment. — If proof were wanting of the varied origin of chorea, it might perhaps be found in the numerous and sometimes conflicting reme- dies, which have from time to time been extolled as successful in its treatment From this circum- stance, indeed, it has been concluded by some that the disease in general subsides spontaneously, and * Med. and Phys. Journ. vol. xv. p. 119, et eeq.; vol, xviii. p. 234; or" Letters concerning the Internal Dropsy of ibe Brain." 1794. is but little under the control of medicine ; a be- lief which receives some degree of countenance from the general tediousness of the complaint, under any mode of treatment It is, doubtless, quite as difficult in this disease as in many others to distinguish between mere sequence and conse- quence. As we have, however, a perfect convic- tion of the efficacy of certain remedies, almost op- posite in their nature to others which have been sanctioned by high authority, we must either ad- mit a difference in the exciting causes, or explain the seeming inconsistency by supposing that one remedy cures the disease by removing the appa- rent cause, and another by correcting some state of the system which may either render it suscep- tible of its influence, or be itself an immediate and essential link between that cause and the symp- toms of the disorder: for example, that of the two most approved methods of treatment in the pre- sent day, purgative medicines may be beneficial by removing causes of irritation from the intesti- nal canal; while metallic tonics may cure the malady by correcting a weak, mobile, or irritable state of the body, without which such irritating causes would not have produced the disease, and in consequence of which, indeed, it may often be prolonged after such causes are removed. Since the publication of Dr. Hamilton's work, " On the Utility of Purgative Medicines," the ad- ministration of cathartics has almost uniformly entered into, if it has not constituted, the sole treatment in chorea. Though it formed perhaps, the principal part of Sydenham's practice in this disease, it had become in a great measure discon- tinued ; and Dr. Hamilton undoubtedly produced by his treatise a most important and useful change in this respect; and proved, in a vast many cases, not only the safety, but the extraordinary efficacy of very powerful cathartics. When the disease is yet in an early stage and scarcely established, gentle aperients may be sufficient, or indeed all that it is proper to administer. But he tells us that in the confirmed stage, when the intestines have in a great degree lost their sensibility, and the accumulation of fasces is great, whoever un- dertakes the cure of chorea by purgatives, must be decided and firm -to his purpose. Powerful medicines must be given, in successive doses, in such manner that the latter doses may support the effect of the former, till the expulsion of the accumulated matter is completely effected. When worms are known to have been passed by the bowels, or are suspected to be the cause of the complaint, the most successful, if not a specific remedy, is the oil of turpentine, in a full dose of from three to six drachms, or more, according to the age of the patient and other circumstances. [The oil of turpentine is a valuable remedy in chorea, whether produced by worms or not. When the bowels have been torpid, and the girl is of an age at which the first occurrence of men- struation may be looked forward to, its advent has appeared to have been hastened, and great relief to be produced by turpentine.] Although purgatives, however, are in many cases the most efficacious remedies, and perhaps necessary in the greater number, both in com- mencing the treatment, and at intervals after- wards, we believe most practitioners will admit 432 CHOREA. that they have often failed in removing the die- ease, and that medicines of another kind have succeeded without their assistance; while Cullen and other high authorities state that they have found repeated evacuations, of any kind, in many cases injurious. In most instances, more especially after the exhibition of purgatives, we conceive that of all remedies tonics are the most successful. Syden- ham used only the vegetable tonics ; and Cullen preferred cinchona to the metallic preparations, as being of safer administration. We think there is no doubt, however, that the latter possess con- siderably more efficacy, and many of them are now found to be perfectly safe, in infinitely larger doses than were formerly considered prudent. The preparations of iron, zinc, copper, silver, and arsenic, are those which have principally been exhibited. Dr. Elliotson has contributed much to establish the efficacy of the subcarbonate of iron in chorea. In the thirteenth volume of the Medico-Chirurgi- cal Transactions, he published an account of eight cases cured by it, and proved that it might, and required to be given in much larger doses than had before been usual. Even the presence of headach, giddiness, and symptoms of paralysis, do not always, he says, forbid its use, but frequently disappear under its exhibition. In four of these cases no purgatives were administered, and in 6ome of the others they could have aided but little in the cure. In his lectures, published in the Medical Gazette, he tells us that he has since cured many dozen cases by the same medicine, and has scarcely failed in a single instance ; and adds that he thinks it will prove effectual in more cases than any other remedy. Occasionally it has been necessary to continue it for three months. (Medical Gazette, vol. viii. p. 653.) The dose of the medicine may at first be from half a drachm to a drachm, increased by degrees to three or four drachms, and taken every six hours, in gruel, mucilage, or treacle; which latter may obviate any constipating effect from it The sulphate of iron has also been found of some efficacy in cho- rea, and may be administered in doses of from one to four grains. [The ferro-cyanuret of iron has been adminis- tered with success,—three grains being given in the form of pill three times a day.] The sulphate of zinc has great power over the disease, and may be given in considerable doses, when they are increased in a gradual manner. The oxyd of that metal, however, is a more manageable preparation, and we have found it of the most uniform efficacy. It may at first be given in doses of five grains, and gradually in- creased. We have given it, in one case, in doses of twenty-five grains. Mr. Bedingfield states that this remedy was so speedily and decidedly successful in the Bristol Infirmary, that he cannot help regarding it as a specific. Upwards of forty cases, occurring there, were, with one exception, cured by it; and he attributes its failure in other hands to its not having been administered with sufficient regularity, or in sufficient doses to excite nausea. Some of the cases, however, were cured without the nauseating effect (Compendium of Medical Practice, p. 51.) [The cyanuret of zinc has likewise been efficacious.] The preparations of copper having been some- times efficacious in other convulsive diseases, such as epilepsy and hysteria, have been given in cho- rea. The sulphate may be administered in doses of a quarter of a grain, or half a grain, twice a dav, and the quantity increased if the stomach will bear it The ammoniuret, or the cuprum ammoniatum, introduced into practice by Cullen, is of safer exhibition, though it should also be begun in very small doses. Cullen states that lie had in some cases increased the dose by degrees to five grains and upwards, and that he had often found it to cure epilepsy. In chorea its virtues do not appear to have been by any means so striking as those of iron and zinc. Dr. Uwins relates a case which got well under its use, combined with digitalis and myrrh. (Edin. Med. and Surg. Journ. vol. viii. p 408.) The nitrate of silver, likewise a successful remedy in epilepsy, has been occasionally admin- istered in chorea. In our own practice it has almost uniformly disappointed our expectations. By others, however, it has sometimes been found successful, as in a case related by Dr. Uwins, in the Edinburgh Medical and Surgical Journal, (vol. viii. p. 407 ;) in two, by M. Priou, in the Medical and Physical Journal, (vol. Iii. p. 262 ;) in another, by Mr. Franklin, in the same work, (vol. xxxiii. p. 273;) and in another, by Dr. Crampton, in the Transactions of the King and Queen's College of Physicians, (vol. iv. p. 114.) The liquor arsenicalis has been used as a tonic, in this as in some other diseases, with consider- able success. Several cases of its efficacy are published in the fourth, tenth, and eleventh volumes of the MeJico-Chirurgical Transactions. In two of these arsenic was the only remedy used, (vol. x. pp. 227, 229 ;) in the others it had been preceded by purgatives. The dose of the solution should at first be three drops thrice a day, and it may be increased to ten drops or more, according to its effects. Of the vegetable tonics, Peruvian bark will be found the most powerful. Cullen says that he found it remarkably useful in this disease. Gen- tian, likewise, and other bitters, have occasionally been of service. De Haen used the leaves of the Seville orange-tree as a stimulant and tonic in spasmodic diseases, with considerable success. Iodine is a medicine which has lately been used with some success in chorea, probably from pos- sessing a tonic and stimulating power. Dr. Man- son has published a number of cases which were successfully treated by it, in combination with mild cathartics. (Medical Researches, &c. p. 187 et seq.) Dr. Gibney, of Cheltenham, has also published two cases in which it was used with success along with other medicines, (Medical Ga- zette, vol. i. p. 54;) and Dr. Peltz relates a similar case in the Philadelphia Journal. (See Med. and Phys. Journ. vol. lix. p. 454.) It may be given in the form of tincture or the solution of the hy- driodate of potass. The former, Dr. Manson directs to be made by dissolving twenty-four grains of iodine in an ounce of rectified spirit; and the dose may be from five to ten or fifteen drops three CHOREA. 438 times a day, in some distilled water. He makes the solution by dissolving twenty-four grains of the hydriodate of potass in an ounce of distilled water; the dose is ten drops to twenty. As the preparations of iodine, however, have been made of various strength by its various advocates, and will probably continue so until admitted into our pharmacopoeias, they ought to be administered with due consideration ; very mischievous effects, and in some cases an affection not unlike chorea itself, having been occasioned by its incautious exhibition. (See Bronchocele.) Of the remedies used for the purpose of giving tone or strength to the system, cold bathing and cold affusion are not to be overlooked. [The Russian bath and sulphurous baths have, like- wise, been found serviceable. (Practice of Medi- cine, 2d edit. ii. 244 : Philad. 1844.)] Electricity and galvanism, also, have been recommended, and the former employed in some instances [especially of late, by Drs. Addison and Golding Bird] with advantage. Narcotic medicines have been frequently used with benefit, though they have occasionally been useless if not injurious. StoU used the extract of belladonna, in doses of one sixth or one fourth of a grain every six hours, with great advantage; and Cullen says that he found opium very gene- rally useful in chorea. (Materia Medica, vol. ii. p. 246.) Dr. Patterson mentions that an unusually severe case in the Bristol Infirmary was cured by opium and camphor; and Mr. Bedingfield tells us that the only case under his observation there which resisted the oxyd of zinc, was cured by laudanum and tartarized antimony. Digitalis has by some been occasionally found of service ; and in the twenty-eighth volume of the Edinburgh Medical and Surgical Journal two cases are re- lated in which the convulsive motions ceased under the use of hydrocyanic acid, preceded by purgatives. Some cases are related in the Medical and Physical Journal, in which a speedy cure was effected by colchicum, without its producing a cathartic, or any other sensible operation. (Vol. xxxi. pp. 181, 292.) [Testimony has been afforded in favour of cimi- cifuga, which, in large doses, is an acro-narcotic. The dried root may be given in powder in the dose of a teaspoonful three times a day ; or it may be given in decoction. (New Remedies, 4th edit. p. 164 : Philad. 1843.)] Musk, valerian, camphor, and other antispas- modics have occasionally been given, but in gene- ral without any benefit Two cases however, are related in the fifth volume of the Medical Trans- actions, in which Drs. Powell and Maton found the first of these successful. The cardamine pra- tensis, also, had at one time a reputation in this disease. Sir George Baker published some cases of spasmodic affection, two of them chorea, in which it appeared to him to be of decided benefit; but there is little confidence now placed in it Although we conceive that in the great majority of cases chorea will be most successfully treated by means of purgatives and tonics, more especially the latter, it cannot be denied that instances have occurred in which there has been such affection of the head as to indicate the propriety of local, or even general bleeding, and other antiphlogistic Vol. I___55 2 m means of cure. Bleeding, as we have seen, was one of Sydenham's remedies ; and Cullen admits that he had in some instances found it useful, though frequently very hurtful. In one case, Dr. Robert Watt found that it had an almost imme- diate effect in allaying the convulsive movements. (Cases and Observations, &c. Paisley, 1808.) Dr. Clulterbuck has in a number of instances prescribed it, at intervals of a few days, ten or a dozen times, and even oftencr, without any other active remedies, and without failing of success. (See his Lectures. Lancet, vol. xii. p. 421.) Dr. Armstrong, who trusted principally to cathartics, aided by diet, exercise, air, and the tepid bath, to restore the functions of the skin, cautions us against the free use of the lancet, and mentions a case, as we stated above, in which it nearly proved fatal. (Lectures. Lancet, vol. viii. p. 70.) The use of external counter-irritants has often been of much service, especially when there has been any considerable affection of the head. Blis- tering the scalp, or rubbing it with tartar-emetic ointment, has been adopted with this indication. The same remedies have been applied in the course of the vertebral column, a mode of treat- ment which accords with the conclusion drawn by Magendie, from the experiments presently to be recounted, that the direct cause of motion is in the spinal chord ; and which would therefore promise, as it has afforded, in cases of a more permanent description, especial advantage. For such purpose, also, a seton in the neck, the moxa, &c. have been recommended. As the disease often arises about the period of puberty, from im- peded menstruation, the application of a blisteT to the sacrum promises to be useful. Dr. Chis- holm states that he found it successful after pur- gatives and antispasmodics had failed. (On the Climate and Diseases of Tropical Countries, p. 97, 8vo. 1822.) Mr. Swan, of Lincoln, found it to have an immediate effect in allaying the con- vulsive motions. (Edinburgh Med. and Surg. Journal, vol. xxii. p. 94.) When chorea arises from the coming of the second set of teeth, lancing the gums, or the removal of some of the first set, will be proper. Instances in which the disease was Rpeedily re- moved in this manner by Drs. Monro and Gre- gory, are referred to in the first volume of the Edinburgh Medical and Surgical Journal, p. 32. Darwin, as he conceived the disorder to arise sometimes from the itch being hastily repelled, begins his directions for the cure by telling us to "give the patient the itch again." (Zoonomia, vol. iv. p. 291.) He also furnishes us with an ingenious suggestion, that perpetual and repeated efforts should be made to move each limb in the designed direction, in expectation of the same good effects that follow from such efforts in stam- mering. Independently of any other benefit from such an exercise, one evident advantage would be, the abstraction of the patient's attention from his complaint— a matter of no slight importance in this and many other convulsive diseases. M. Louvet Lamarre found the exercise of the skip- ping-rope of much use in one instance. (Med. and Phys. Journ. Vol. Ix. p. 89.) On this sub- ject Dr. Mason Good remarks that a long and punctual discipline of the affected limbs to regular 434 CHOREA. and measured movemenfs, might, where the dis- ease is not very severe, recal them to their wonted order and firmness ; and adds that with this view the exercise of dancing, by which the original chorea Sancti Viti is said to have been cured so singularly, may be well worthy of attention. (^:udy of Medicine. Vol. iv. p. 485.) The in- fluence also of music alone, independent of the measured efforts in dancing, ought not to be overlooked. In some of the diseases resembling the original St. Vitus's dance, as we shall pre- sently see, an extraordinary passion for music has been among the most prominent symptoms ; and Dr. Armstrong relates a case in which music had the effert of procuring sleep, and of ultimately curing the diseise altogether, after it had resisted purgatives, sulphate of zinc, the arsenical solution, and various other means. (Lectures. Lancet. Vol. viii. p. 70.) When the will retains any power over muscular action, as it does in the ordinary form of the malady, it might be expected that such power, in a person susceptible to music, would be irresistibly or unconsciously exerted, to reduce the erratic movements as much as possible into harmony with its measured cadences. Nor will this appear fanciful to any one, who, being endowed with a musical ear, may have experi- enced how difficult it is, while music is sounding, even to obey the will in movements which do not accord with its measures. [Under the head of chronic chorea, Dr. Wat- son (Lectures on the Principles, df-c. of Physic, Amer. edit, p. 364 : Philad. 1844,) has placed partial choreas, tics, spasmodic tics, or nervous tics, which consist in the most irregular and fan- tastic movements of certain muscles,—at first dependent upon bad habits, badly regulated vo- lition, but subsequently executed independently of all volition. At times, they arise in conse- quence of some morbid condition of the nerves, and in spite of every effort of the individual. There is no plan of treatment which can be ser- viceable in such cases. Mental attention, with appropriate revulsion, may be sufficient; but if not, every other agency must fail. There is no danger, however, in these affections.] We shall now advert to those singular affec- tions which seem to have been erroneously classed with the foregoing disease, as well as to some others which appear to have been equally entitled to the appellation of chorea. There is the following curious account of the original chorea Sancti Viti, in Burton's Anatomy of Melancholy. « Chorus Sancti Viti, or St. Vi- tus's dance ; the lascivious dance Paracelsus calls it, because they that are taken with it can do no- thing but dance till they be dead or cured. It is so called, for that the parties so troubled were wont to go to St. Vitus for help ; and after they had danced there a while, they were certainly freed. 'Tis strange to hear how long they will dance, and in what manner, over stools, forms, tables; even great bellied women sometimes, (and yet never hurt their children,) will dance so long that they can stir neither hand nor foot, but seem to be quite dead. One in red clothes they cannot abide. Music above all things they love; and therefore magistrates in Germany will hire musi- cians to play to them, and some lusty sturdy com- [ panions to dance with them. This disease has been very common in Germany, as appears by those relations of Schcnkius, and Paracelsus in his Book of Madness, who brags how many seve- ral persons he hath cured of it Felix Platerus (de Mentis Alienat cap. iii.) reports of a woman j in Basil, whom he saw, that danced a whole month together," (Vol. i. p. 15. 8vo. edition. Lon- don, 1826.) This malady appears to have been generally considered as a disease of the mind, and we learn from Horstius and others, that it was liable to recur every year at the same period. The movements do not seem to have been actually spasmodic, but rather to have arisen from an irre- sistible propensity to muscular action, increased to a sort of phrenzy by the sound of music and the force of imitation. The frequency of the dis- ease, as reported, however, gives rise to suspicions of imposture. Baglivi, who has given us an account of some- what similar symptoms arising from the bite of the tarantula, or venomous spider, in Apulia, and cured exactly in the same manner, states that the disease was very often counterfeited by the wo- men, who in that country lived solitary lives, for the purpose of enjoying the agreeable diversion of music and dancing, which was only allowed to those afflicted with the malady. " In fine," says he, " the musical entertainment of this country" (in allusion to the mode of curing the disease) " is so very agreeable to the women, that 'tis a proverb with us, ' II carnevaletlo delle donne.'" He informs us, however, that there really was an unfeigned disease arising from the bite of the ta- rantula ; Sauvages has named it tarantismus; and says that " those who are stung die in a little time without the present assistance of music, all other remedies giving no relief." His description of the symptoms and the mode of cure are very singular. " A few hours after the bite," says he, " the patient is seized with a great difficulty of breathing, a heavy anguish of heart, and a prodi- gious sadness," &c. The malady, "after the sharp fit of the. violent symptoms, which appear for the first days, is over, ends at last in a peculiar kind of melancholy, which continually hangs upon the sick person, till by dancing, or singing, or change of air, those violent impressions are quite extirpated."—" Many of these persons are never well but among graves and in solitary places; and they '11 lay themselves along on a bier, as if they were really dead ; they '11 throw themselves into a pit as if they were in despair. Maids and women, otherwise chaste enough, with- out any regard to modesty, fall a sighing, howl- ing, and into very indecent motions, discovering their nakedness ; they love to be tossed to and again in the air; and the like. There are some that will roll themselves in the dirt like swine, and are mightily pleased with the exercise. Others, again, you cannot please, unless they be soundly drubbed on the breech, heels, feet, back, &c. And there are some that take a great pleasure in run- ning. There are also curious observations made about colours; some of which are very agreeable to those persons, as others are offensive to them." In describing the manner in which thev are work- ed upon by music, he says, " When any are stung, shortly after it they fall down upon the ground, CHOREA. 435 half dead, their strength and senses going quite I from them. Sometimes they breathe with a great deal of difficulty, and sometimes they sigh pite- ously ; but frequently they lie without any man- ner of motion, as if they were quite dead. Upon the first sounding of the music the forementioned symptoms begin slowly to abate; the patient be- gins to move his fingers, hands, feet, and succes- sively all the parts of the body ; and as the mu- | sic increases, their motion is accelerated ; and, if he was lying on the ground, up he gets, (as in a j fury,) falls a dancing, sighing, and into a thou- ! sand mimic gestures. These first and violent motions continue for several hours, commonly for two or three. After a little breathing in bed, where he is laid to carry off the sweat, and that he may pick up a little strength, to work he goes again, with as much eagerness as he did before, and every day spends almost twelve hours by the clock in repeated dancing; and, which is truly wonderful, so far is he from being wearied or spent by this vehement exercise, that (as they say) it makes him more sprightly and strong. There are, however, some stops made; not from any weariness, but because they observe the musical instruments to be out of tune ; upon the discovery of which, one would not believe what vehement sighings and anguish at heart they are seized with; and in this case they continue till the instrument is got into tune again, and the dance renewed. This way of dancing commonly holds four days, it seldom reaches to the sixth. Every patient has not only his particular tune, but also his particu- lar instrument; some a pastoral pipe, others a lit- I tie drum, cittern, harp, timbrel, violins, and pipes of several sorts. Here 'tis remarkable that some- I times the musicians will tune three or four differ-; ent sorts of sounds without having the least effect upon the patient. But when they fall into a tune that's accommodated to the poison, they presently receive the benefit of it. However, this must be I taken for a truth, that how much soever they vary in their particular tunes, yet they all agree in this —to have the notes run over with the greatest quickness imaginable, (which quickness of sound is commonly called tarantella.) And therefore the players that have not their lesson to learn in these matters, easily discover the cheat of the wo- men ; for if they find that they presently take any motions, and jog on indifferently, without any regard to the swiftness, slowness, or other differ- ence of sounds, they give to understand that the honest woman is but in jest, and afterwards expe- rience puts the matter out of doubt," (Baglivi's Practice of Physic, p. 363 to 382, passim. Lon- don, 1704.) He states that the disease, like the German chorea Sancti Viti, generally returned about the same time of the year that the patient w.as stung; and seems much at a loss to under- stand either how it was produced, or in what manner it was cured. He appears inclined, in- deed, to account for the latter, by the profuse sweatings induced by the violent exercise ; but he admits that the physicians could not cure it by artificial sweatings. A cony which was stung by a tarantula and died on the fifth day after, was not at all influenced by music. On opening it I after death, he tells us that " the veins and arte- ries of the brain were swelled up, and the brain j itself a little inflamed, and set about with black- ish spots here and there. The lungs and other entrails were distended with clotted and black blood. In the ventricles of the heart were ob- served greater clots of blood, and small branches of a polypous concretion. There was abundance of serum lying about the outward parts of the brain. The other parts were sound and untaint- ed." (Page 386.) There is a case related in the New York Repository, (Hex. ii., vol. i., p. 1-11. Med. and Phys. Joum. vol. xv.), of a convulsive disease, ascribed to the bite of a spider, which, like that from the tarantula, was most effectually counteracted by music. In the latter malady, as as in the original St. Vitus's dance, the principal peculiarities were the excessive love for music, and desire of muscular motion, especially in regu- lated measures. In both there was a liking or dislike of certain colours ; and in both, the ima- gination at least, if not the intellect, was from the commencement disordered. Such, however, it is almost needless to observe, are far from being the characteristics of the ordinary chorea. Mr. Kinder Wood has related a singular case in the Medico-Chirurgical Transactions, which he names chorea Sancti Viti; and it certainly had much in common with the original disease of that name. The patient, a married woman, aged twenty-two, after complaining of severe pains in the right side of the face, succeeded by heaviness and wildness of the eyes, became affected with ex- traordinary involuntary motions, commencing in the eyelids, which were opened and shut with ex- cessive rapidity. They then affected the muscles of the extremities. The palms of the hands were beat rapidly on the thighs, and the feet on the floor, the arms being at limes extended, the palms turned outwards and inwards, and the backs of the wrists struck violently on each other, or the middle fingers on the palms of the hands with great quickness. The motions soon extended to the trunk of the body and the pelvis; and the patient was half raised from the chair, and in- stantly reseated in rapid succession. Sometimes she was forcibly thrown on her feet, when she jumped and stamped violently, and she had often a propensity to spring or leap upwards; and strike the top of the room with the palm of the hand. Frequently she would dance on one leg, holding the other with the hand. These attacks were accompanied with headach, sickness, and vomit- ing, which generally succeeded the affection of the eyelids. On the third day she began to strike the furniture and doors violently with her hand, and was greatly pleased with the sound. At length the bystanders observed that the strokes assumed a regular tune and measure, and the motions were changed into a step about the room, regulated by an air, or series of strokes upon the furniture as she passed. Though, previous to her illness, she could not even dance a country dance, she would now move about in all the elegance of a minuet. When she looked around, she had an irresistible propensity to spring up and touch lit- tle spots or holes in the ceiling ; and she would dart the forefinger with amazing rapidity and pre- cision through a hole in a wooden screen. A per- son, thinking he recognised the tune which she beat on the furniture, began to sing it, and she 436 CHOREA. danced directly up to him, and continued dancing till she was out of breath. A drum and fife were now procured, and she immediately danced up to the drum, and as close to it as possible, till she missed the step, when the motions instantly ceased, and this was always found to be the case. The motions were always found to cease, also, when the measure was changed, or increased in rapidity beyond her power to keep pace with it. When a continued roll was kept up on the drum, it had likewise the effect of stopping the motions. Their approach was therefore watched, and by uniformly rolling the drum when it was observed, the chain of associations which constituted the disease was at length broken. Mr. Wood states that the alvine excretions were unnatural during the complaint, and that the menstrual discharge appeared on the evening of the day on which it ceased ; together with an eruption on the skin, in diffused patches, of a bright red colour. Whether these were essential circumstances in the history of the case is a question worthy of consideration. Mr. Wood thinks that the case establishes the connection of such instances of inordinate muscu- lar action with some peculiar state of the mind. He tells us, however, that the patient's spirits were good, her perception and judgment accurate and just; that during the absence of the parox- ysms she went about many household affairs ; and that she had a correct knowledge of her situa- tion, and of the advantages she derived from the agency of the drum, with an anxious desire to continue its use. A subsequent less severe attack of the complaint disappeared under the use of aperienis and tonics; and the third and last, which terminated in spasmodic affections of the abdo- men, chest, neck, and face, seems to have been chiefly benefited by bleeding. It is curious that, after the nature of the motions was changed in this last attack, the drum had no effect upon them. (Medico-Chirurg. Trans, vol. vii.) [In another work, (Practice of Medicine, edit. cit. ii. 295,) the author has given, on the autho- rity of a young medical friend, an account of a singular affection said to be somewhat common in the southeastern portion of the state of New York, and known among the common people as the magrums. It is said to consist essentially in a spasmodic action of all, or nearly all, the volun- tary muscles. In the involuntary movements, the upper part of the air-passages occasionally parti- cipate, as witnessed by a clucking sound in the neighbourhood of the glottis, and a manifest im- pediment in the powers of speech. The move- ments of the face, neck, extremities and body, wholly cease during sleep. The disease very rarely makes its appearance before adult life, and attacks after forty-five years of age are very rare. It rarely or never ceases whilst life lasts, and ap- pears to be hereditary.] Of the disease which has been at times preva- lent in some parts of Scotland, and known by the name of " the leaping ague," the following is a concise description :—" Those affected first com- plain of a pain in the head or lower part of the back, to which succeed convulsive fits or fits of dancing at certain periods. During the paroxysm they have all the appearance of madness, distorting their bodies in various ways, and leaping and springing in a surprising manner, whence the dis- ease has derived its vulgar name. Sometimes they run with astonishing velocity, and often over dangerous passes, to some place out of doors, which they have fixed on in their own minds, or perhaps even mentioned to those in company with them, and then drop down quite exhausted. At other times, especially when confined to the house, they climb in the most singular manner. In cottages, for example, they leap from the floor to what are called the baulks, or those beams by which the rafters are joined together, springing from one to another with the agility of a cat, or whirling round one of them with a motion resem- bling the fly of a jack." (Edin. Med. and Surg. Journal, vol. iii. p. 835, or the Statistical Account of Scotland, by Sir J. Sinclair, passim.) The most recent published case of this disease, so far as we are aware, will be found in the 31st volume of the Edinburgh Medical and Surgical Journal. Mr. Crichton states that the patient was a girl fifteen years old, and that the affection was announced by frequent shakings, with foam- ing at the mouth, followed by coma. In addi- tion to many of the symptoms mentioned in the foregoing passage, such as dancing, jumping upon the furniture of the room, running round a table, springing on the top of a door to swing backwards and forwards, leaping over a staircase at one bound, and desiring to spring out of a window ; she had likewise the following singular affection : " she would occasionally converse with those in the room, but in a language that no stranger, and hardly even those of the family who were con- stantly beside her, could understand. This arose from her commencing the sentence with the last word, and very frequently pronouncing the words themselves with the last letter foremost. At times, when by no possibility she could make herself be understood by her parents or sisters, she became irritated, and would write down what she wished to convey ; but her manner of writing was equally singular, beginning at the right edge of the paper, and writing backwards towards the left, the last word of the sentence first, and often the last letter of the word first; and this she per- formed with great rapidity, and seemingly without consideration." (Vol. xxxi. p. 300.) She had a propensity to secrete things; and so irresistible were the impulses to motion, that the strength of several people was insufficient to constrain her. Purgatives afforded her little benefit Opium be- fore the paroxysm sometimes prevented it; and the shower-bath cUred the disease, though it pro- duced locked jaw for eight days. The " leaping ague" may be said to consist, generally, of a mor- bid propensity to running, leaping, dancing, or tumbling, which the patient is unable to resist The muscular motions, though in a great degree involuntary, are performed with more agility and exactness than usual; for the person affected can run with greater velocity, leap with greater vigour, and do feats which even professed tumblers could not equal, balancing the body with correctness, and dexterously avoiding dangers. It is scarcely necessary to point out how widely the disease differs in all these respects from the ordinary chorea. M. Piedagnel has related the case of a man, CHOREA. 437 who, after some symptoms of cerebral affection, was seized with an irresistible propensity to move forwards, only stopping when exhausted. Find- ing his apartment too confined for the gratification of his propensity, he would sally into the streete, and continue walking straight forward until he dropped down, and was obliged to be brought home in a litter. On opening the head, several tubercles were found, involving in a particular manner the anterior part of the hemisphere. (Journal de Physiologie, torn. iii. or Magendie's Physiology, translated by Dr. Milligen, 3d edit. p. 189.) In direct opposition to this case, Dr. Lau- rent, of Versailles, exhibited a young girl to the Academy of Medicine, who, in the attacks of a nervous disease, was irresistibly propelled back- wards, and with some rapidity, being unable to avoid obstacles or hollows, and, consequently, re- ceiving many bruises and falls in her course. (Magendie's Physiology, p. 191.) An account of a very remarkable case, in which a young girl, in Renfrewshire, was affected with violent fits of leaping, dancing, running, crying, fainting, &c., was published at Edinburgh, in 1698. It was entitled " A True Narrative of the sufferings of a Young Girl, who was strangely molested by Evil Spirits, and their Instruments, 6tc." The disease being ascribed to witchcraft, a commission was appointed by the king to inquire into the matter, and seven unfortunate beings in consequence were condemned to the flames! One of the most extraordinary cases of convul- sive disease on record has been related by Dr. Robert Watt, of Glasgow, in the 5th volume of the Medico-Chirurgical Transactions, under the title of Chorea, or <■ Periodical Jactitation." The patient was a lively, but rather delicate girl, ten years old, from Ayrshire. She was first seized with excruciating headach, and almost incessant vomiting, increased by the slightest inclination of the body either backwards or forwards. These symptoms continued for a month, during which time she lost the power of speech and of walking. At the end of that time she was seized with a propensity to turn round on her feet, like a top, with great velocity, always in one direction, and was gratified when the attendants assisted her in increasing the rapidity of her movements. After continuing nearly a month these motions ceased, the headach returned with increased severity, and was succeeded by a total loss of power over the muscles of the neck. In a short time after, she was seized with a new kind of motion. She would lay herself across the bed, and, turning round like a roller, moved rapidly from one end of it to the other. The fits continued at first for about two hours; but they gradually increased to six or seven hours daily. On being carried into the garden, she rolled rapidly from one end of a walk to the other ; and, even when laid in the shallow part of a river, though at the point of being drowned, she began to turn round as usual. Nor did the sudden dashing of cold water over her interrupt her movements. Her rotations were about sixty in a minute. In a month or six weeks, ! the movements became of an entirely new kind. The patient now lay upon her back, and, by drawing her head and heels together, bent herself like a bow, and then allowing her head and heels 2m» to separate, her buttocks fell with considerable force upon the bed. She repeated these move- ments ten or twelve times in a minute; at first for six hours daily, and at length for fourteen. After this had continued for about five weeks, she was seized with a propensity to stand upon her head with her feet perpendicularly upwards. As soon as the feet were elevated in this manner, all muscular exertion seemed to be withdrawn, and the body fell down as if dead; her knees first striking the bed, and her buttocks striking her heels. This was no sooner done than she in- stantly mounted as before, and continued to do so, from twelve to fifteen times in a minute, for fifteen hours a day. The disease left her after a spontaneous diarrhoea, having previously resisted cathartics, an emetic, local bleeding, blistering, a seton in the neck, &c. Dr. Watt states that an- other instance, similar to this, had occurred some years before in Ayrshire, and that he had been informed of a third in the same county: in both of these, also, the patients were young women. There is a case mentioned in the 3d volume of the Edinburgh Medical and Surgical Journal, page 437, in which a young girl was affected with a species of motion similar to the first which Dr. Watt's patient presented. ♦• Her complaint began with convulsions of the diaphragm and abdominal muscles, producing an action like retching, or something between hiccough and retching. Con- vulsions of the extremities supervened, and in the paroxysms, which lasted several hours, she per- formed the most singular motions; at one time bounding upon her bed, then turning round and round, as upon an axis; then running round the outside of the ropes by which her hammock was suspended." She had several paroxysms a day, coming on at stated intervals, and she had con- stant pain, which she referred to the region of the uterus. Nothing was discovered on dissection after death, which could at all explain the nature of the disease : some time before she was affected, she had rather a severe fall upon her head. Mr. Hunter, of Glasgow, relates a case in which the principal symptom was a convulsive rotation of the head and trunk; he entitles it, therefore, " rotatio," or chorea. The patient was a female, twenty-three years old, and unmarried. While lying on her back, the head was rolling from side to side, with a quick, regular, and continued movement. When a fit came on, " she sprang with a strong convulsive movement from her back, and sat up in the bed. The rotatory motions of the head now became furious and alarming. They were executed with such immense rapidity, that it was difficult even for eye to follow them. She appeared absolutely to be looking backwards and forwards, and in every direction, at the same in- stant. The movements, while in the sitting pos- ture, were not confined to the head ; for the whole trunk likewise partook of the rotatory motions, the breech being the pivot upon which the whole turned. These convulsive motions continued about a minute, when they took a new but equal- ly strange direction. The flexor and extensor muscles of the head and trunk were altcmately called into action, and without the breech it the patient moving from its first position, her head was rapidly carried forwards to her knees, and 438 CHOREA. backwards to her pillow, for about half a minute, when the paroxysm ceased, and left the patient greatly exhausted." (Edinb. Med. and Surg. Journal, vol. xxiii. p. 261.) She was perfectly rational, but the external senses were blunted and torpid. She sometimes had fifty paroxysms in a day. The disease appeared to commence in the uterine region, where there was pain on pressure; and it was cured by rubbing tartar emetic oint- ment on the scalp, and along the course of the vertebra?. A case in some respects similar to this has occurred in our own practice, in the person of a young woman, who was affected for a long time with rotation of the head, without pain, but accompanied by intolerance of light The mo- tions, however, were far more gentle and slow than in Mr. Hunter's case, and they were unin- termitting. A patient attended by Dr. Conolly became subject, about the period of the cessation of the catamenia, and when menstruation had become irregularly performed, to violent paroxysms of rotation : they occurred many times in a day, and were always preceded by an inordinate disposition to talk. When the fits came on, the head was forcibly rotated from side to side about eight times in a second, and the paroxysm commonly lasted three or four minutes. In this case, the affection yielded to cupping behind the neck, application of leeches to the head, and the persevering use of aloetic purgatives. Another singular form of disease, which has at times been ranked with chorea, is that affection, by some authors called malleatio, and consisting, principally, of a striking of the knees with one or both hands, as with a hammer. The hands are generally open, but sometimes they are clenched. Morgagni mentions a case of this description, in which one hand was convulsed ; on extending any of its fingers the other hand became affected also; and if attempts were made to arrest the mo- tions by force, they became both more violent and more general. We ourselves recollect the case of a man, in the Hampshire County Hospital, in whom there was a constant and uniform striking of the palm of one hand upon the side of the thigh, to such a degree, as speedily to wear out the part of his dress on which it fell. In the preceding cases of anomalous convul- sions, it will be observed that there was for the most part a periodical return and intermission of the spasms, as well as some method or regularity in the movements themselves. In both these re- spects they differ from the common chorea of this country. Other cases have been met with, oc- curring in paroxysms, but in which the motions were obedient to no rule or method. Dr. White, of York, describes a case of this kind in the fourth volume of the Edinburgh Medical Commentaries, p. 326, in which the muscles of various parts were, not simultaneously, but in su< cession, pain- fully convulsed, producing appearances so gro- tesque as to defy description. Three cases, oc- curring in one family in the county of Rutland, are related by Dr. Armstrong, in the ninth volume of the same work, p. 317, in which the patients were affected periodically, and suddenly, with fits of shrieking, jumping, writhing, &c. The disease first occurred after hooping-cough, and Dr. Arm- strong considered it as epileptic. There are some singular instances recorded of affections like the last being propagated by sym- pathy or imitation. These have generally been attended, and in the first instance, excited by religious or some other species of enthusiasm. This was strikingly the case in that extraordinary epidemic, as it has been called, which prevailed in 1742 in the parish of Cambuslung, in Lanark- shire, during the ministry of Mr. Macculloch, and produced by his preaching and exhortations on the subject of regeneration. (Edinb. Med. and Surg. Journ., the Inquirer, No. 11), vol. iii. p. 441). A similar epidemic occurred in the western districts of America, in consequence of the elec- trical spread of religious enthusiasm throughout the states of Tenessee and Kentucky, about the year 1800. Dr. Robertson, who published an account of it, states that the conveits indulged in alternate fits of coughing, laughing, singing, shouting, and extravagant gesticulations, until, at length " to their own astonishment, and the diver- sion of many of the spectators, they continued to act from necessity the curious character which they had commenced from choice."* He informs us that the convulsions were generally in the muscles of the neck, trunk, and superior extremi- ties ; and that they were sometimes so violent as to throw the patient on the ground, " where, for some time, his motions resembled those of a live fish when thrown on land, more than anything else." M. Magendie relates a case of the most extraor- dinary nature, in which the power of the will over the muscular motions was, at intervals, entirely lost; but instead of the muscles being paralysed or remaining at rest, they were abandoned to the most irregular and indescribable movements for hours together. After stating that the disease was preceded by great mental anxiety, followed by melancholy, the understanding remaining how- ever entire in all other respects, M. Magendie describes the peculiar symptoms of the case in the following words : " It is impossible to paint, by language, the variety and oddity of his motions and positions. Had he lived in the times of igno- rance, he would, beyond all doubt, have passed for one possessed ; for his contortions were so far removed from the motions proper to mankind, that they might easily have passed for diabolical. It was worthy of remark that, in the midst of these contortions, in which his slender and pliant body was sometimes carried forward, sometimes thrown back, or to one side, like certain tumblers, he never lost his equilibrium ; and that in the multiplicity of attitudes and singular motions which he exhibited for several months, he never once happened to fall. At certain times his mo- tions would pass into the train of ordinary actions. Thus, without the least participation of his will, he was seen to rise and walk with rapidity, until he met with a solid body that opposed his passage. Sometimes he walked backwards with the same readiness, and was only stopped by a similar * Edin. Med. and Surg. Journ vol. iii. p. 440; or an Inaugural Essay on Chorea Snncti Viti, by Felix Robert- I son, of Tennessee. 8vo. Philadelphia ltu5 CHOREA. 439 cause. He has often been observed to re-assume the power over certain motions without being in any way capable of directing others. Thus his arms and hands frequently obeyed his will, and more frequently still, the muscles of his counte- nance and speech. It was sometimes possible for him to retrograde in an instant, where progression forwards was anyhow prevented ; and he then employed that retrograde motion to direct himself towards objects to which he wished to attain. Finally, these movements, which might be called automatic, never lasted an entire day. He enjoyed pretty long quiet intervals between the accessions ; his nights were always tranquil. Although his muscular contractions were extremely violent, even to the extent of producing abundant sweats, when they had ceased, he perceived no sensation of fatigue in proportion to the efforts which he had made; as if the intellectual action which we exert to excite our motions were that which in the healthy suffers most exhaustion." (Compen- dium of Physiology, pp. 201 and 202). The causes of such anomalous cases of convul- sion, and the manner in which they operate, are exceedingly obscure. Modern physiologists, how- ever, have afforded us some light on the subject. Thus, Magendie has, by experiments on some of the lower animals, shown great reason to believe that the will has more particularly its seat in the cerebral hemispheres, while the direct cause of motion is in the spinal marrow. We can easily conceive, therefore, says he, " why, in certain cases, these motions are not produced, though commanded by the will; and why, in certain cir- cumstances of a contrary nature, very extensive and energetic motions are developed without any participation of the will." (Op. cit. p. 202.) In some of the following experiments confirmatory of this view, it will be observed that many of the anomalous symptoms in the cases we have just related, were produced by artificial means. M. Magendie found that the cerebral hemi- spheres might be deeply cut into, or even entirely removed, provided the corpora striata were not injured, without any marked alteration of motion taking place. In a number of cases he has seen birds, reptiles, and fishes, run, leap, and swim, after the hemispheres were removed. Neither does the longitudinal section of the corpus callo- sum, or its entire removal, produce any additional effect upon the motions. But if the corpora stri- ata be removed, the animal immediately darts forward, and runs rapidly, as if impelled by a power within which it cannot resist. This effect arises from the destruction of the white and stri- ated portion of these bodies, for the removal of the brown matter does not produce any change in the movements of the animal. In unison with these facts, M. Magendie has opened several im- moveable horses, or horses that cannot go back- wards, though they can move forward with rapidity ; and he has in all of them found a col- lection of water in the lateral ventricles, which must have compressed the corpora striata, and had even disorganized their surface. He considers it extremely probable, therefore, that there exists in man and the mammalia a force or impulse which tends to carry them forward, and which in a state of health is directed by the will. Again, both he and others have found that lesions of the cerebel- lum cause animals to move backwards contrary to their will. He found also that injuries of the medulla oblongata produce the same effect. Pigeons, into which he forced a pin through that part, constantly receded, for more than a month, and even flew backwards. The energies of the cerebellum and medulla oblongata appear, there- fore, to be directly opposed to those of the corpora striata; those of the one counterbalancing the other in the sound state, and being rendered pre- ponderant, or otherwise, by disease or injuries of the respective parts. A still different effect was produced upon the movements of the animals when the peduncles of the cerebellum were divided. In that case the creature rolled laterally upon itself, as if impelled by a great force ; the rotation being made upon the side on which the peduncle was cut; the animal making sometimes more than sixty revolutions in a minute, and the motions continuing frequently for eight days j without a moment's interval. The same effect was produced by vertical and entire sections of the cerebellum ; the motions being more rapid according as the section was nearer to the origin of the peduncles. When the cerebellum was cut vertically into two perfectly equal parts, the animal first rolled once or twice to one side, and then as often to the other, as if for relief. Similar effects to these were obtained by sections of the pons j varolii, which, together with the peduncles of the cerebellum, forms a circle round the medulla | oblongata. Sections to the left of the median line produced rotation to the left, and sections on the right side of the line, rotations to the* right. A movement in a circle, resembling that of the manege, was occasioned by a section of the me- dulla oblongata, where it approaches the exterior of the anterior pyramid. If cut on the right side, the animal turned to the right; and when cut on the left, it turned to the left. Lastly, when the spinal marrow was separated from the brain by a section made behind the occipital bone, the influ- ence of the will appeared to be entirely cut off from the movements; which, however, did not cease, but became very irregular in extent, rapidity, duration, direction, &c. (Compendium of Physi- ology, p. 187 to 193—200 and 201.) These experiments, as well as those of Rolando and of Flourens, are strongly in favour of the opinion, that individual parts of the brain answer individual purposes, so far, at least, as regards the power of regulating our movements. Such sin- i gular and anomalous instances of muscular action, therefore, as those we have related, may arise from causes which produce an excitement or oppression of certain parts of the encephalon, without affect- ing the other parts. Certainly in many, or most of the cases, marks of cerebral affection were ob- served. In M. Piedagnel'scase.as we have already mentioned, several tubercles were found pressing i upon the brain ; in the immoveable horses, water was uniformly discovered in the ventricles ; in the rabbit that died from the bite of the tarantula there were marks of inflammation, congestion, and effu- sion of scrum on the brain. In the leaping ague, one of the first symptoms is pain in the head. Dr. Watts's case was preceded by excruciating head- ach and incessant vomiting; Mr. Kinder Wood's 440 CLIMATE, was attended with the same symptoms ; and the j patient whose case is referred to in the third volume of the Edinburgh Medical and Surgical Journal, had had a severe fall on the head some time previous to the convulsive affection. Al- though the existence, therefore, of partial pressure J or other affections of the brain may not in all j cases have been discovered, or even discover- able,— since, unless it arise from a permanent cause, it maybe impossible to detect it after death, i — yet it must be admitted that there are strong j grounds for attributing these cases to such an origin, and for directing our remedial attentions ac- cordingly. Whether the strange mental or mono- maniacal symptoms which have sometimes ac- companied the convulsive motions, may, as well as the latter, be attributed to an affection of cer- tain individual parts of the brain, is more problem- atical. The disciples of Gall and Spurzheim, however, would doubtless advert with complacency in Mr. Wood's case to the prominent symptoms of excitement in the vicinity of their organs of time and tune, as confirmatory of their doctrines. [See Watson, Op. cit., p. 367.] Andrew Crawford. [CIRRHOSIS. (See Ltvee, Diseases of the.) CIRRHOSIS OF THE LIVER. (See Liver, Diseases of the.) CIRRHOSIS OF THE LUNG. Under this name, Dr. Corrigan, of Dublin, has described a pathological condition, the general character of which is a tendency to consolidation or contrac- tion of the pulmonary cellular tissue with dilata- tion of the bronchial tubes. The diminution of the lung is regarded by him as the first step of the disease, and the dilatation of the bronchia the con- sequence of this. The primary seat of the disease he considers to be—the web of cellular tissue, con- stituting the matrix of the lung, which has a ten- dency to contract, so as to produce, when the dis- ease is advanced, a very considerable obliteration of the air-cells. (Dublin Med. Journal, May, 1842, and the writer's Practice of Medicine, 2d edit, i. 201 : Philad. 1844.)] Robley Dunglison. CLIMACTERIC DISEASE. (See Age.) CLIMATE. The general import of the word climate (from icXl^a, regio,) is sufficiently under- derstood, although it is not easy to give an accurate definition of it. In medicine the term is used to designate those habitual conditions of the atmo- sphere, in connection with the state of the surface, soil, exposure, &c. of particular countries or dis- tricts, which are capable of influencing the health of persons inhabiting them. The subject of climate may be treated under two distinct divisions, physical and medical. The consideration of the former, or physical climate, we must leave to the natural historian, as not com- ing properly within the scope of this work, al- though affording matter of the greatest interest to the medical philosopher. The latter or medical climate, may also be considered under two sepa- rate heads—as it affects the body either in causing or curing disease. The latter part of the subject, or the consideration of climate as an agent in the prevention and cure of disease, is that which we propose to treat in the present article; availing ourselves, however, of the physical cha'arters of climate and the geography of disease, as far as a knowledge of these departments of the subject tends to illustrate the medical application of climate. We shall first give a brief account of the cli- mate of the principal places in our own Island, in the South of Europe, and in the Northern Atlan- tic, which have been most frequented by invalids; and endeavour, at the same time, to determine their respective characters and their relative merits. We shall then point out the diseases which are most decidedly benefited by change of climate, and the particular situations most suitable to each. The influence of climate on the animal economy is now so well known and appreciated by the more observant part of the profession, that it would be a waste of time, in a work of this nature, to enlarge upon the advantages which may be derived from a well-timed and judicious change of it in the treatment of disease. The removal, for example, from a cold, humid, and variable cli- mate, to one which is warm, dry, and more equa- ble, is well known to be productive of the most beneficial effects on a large class of invalids, when other therapeutical agents are of little avail; while, on the other hand, a contrary change is as certainly attended by a deterioration of the health, and often by the supervention of fatal diseases, even in persons previously in the enjoyment of good health. If our limits permitted, it would not be difficult to account for many of the effects of climate, whether favourable to health or the reverse. For instance, when we reflect on the powerful in- fluence of a warm dry air on almost all the func- tions of the animal economy, but more especially its obvious agency in promoting an equable dis- tribution of the circulating fluids over the whole system, and particularly its effect in augmenting the activity of the circulation in the capillaries of the surface, and in diminishing in the same pro- portion the congestion of the internal vessels, (a state which very generally obtains in chronic ailments,)—we have a satisfactory explanation of much of the benefit which invalids experience by a removal from a cold to a warm climate. If we take into account also the. effect of the continual action of a bland atmosphere on the extensive surface of the respiratory organs, both as abating irritation of the lungs, and enabling them more effectually to produce those changes in the blood that are essential to health, we have another very obvious explanation of the results observed. And if to these we add the influence produced on the nervous system generally, on the external senses, and through them on the mind, and, reversely, the re-action of the mind on the bodily functions — we need have little difficulty in accounting for the beneficial influence of the change of climate which we are now considering. The contrary state of the functions and of the circulation, and the diminished energy of the nervous system induced by a change from a genial to a cold and humid climate, will with equal readiness account for most of the evil con- sequences so frequently observed under such cir- cumstances. Independently, however, of these effects, more [ directly attributable to climate, properly so called, CLIMATE. 441 there arc many incidental circumstances attending ] a change of this kind, which have often no small ' share in improving the condition of the invalid. ' The hopes inspired by the measure itself, the in- ' fluence of the journey or voyage, the change' of scene, of occupation, and often, also, the escape from business and other sources of discomfort and care, all claim a part in the benefit produced. While all these circumstances will, therefore, have their due weight with the physician, when deciding upon such a change of climate as we are now contemplating, he must not omit, at the same time, to take into account the inconveniences and even disadvantages, which in many cases are inseparable from the removal of the delicate in- valid from his own home and country. These latter considerations will rise in importance in his mind according to the advanced state of his pa- tient's disease, and consequently the diminished prospect of permanent advantage from the mea- sure. So many circumstances of a conflicting nature often present themselves for our considera- tion in such cases, that it is only by a compre- hensive and dispassionate view of all the bearings of the case that we can come to a right decision, and then often not without difficulty. It is per- haps the rarer case, that we have merely to con- sider the nature of the patient's disease, and the probability of its being benefited or cured by any particular climate. Among the numerous circumstances which require attention in recommending a change of climate, one of much importance is often entirely lost sight of, both by the physician and his pa- tient :—we mean the necessity of perseverance in the regimen and mode of life which the peculiar nature of the disease demands. This must be urged upon the invalid as the condition on which alone he can expect to derive benefit from the prescribed measure. We would press upon the minds of our pro- fessional brethren the importance of giving a full consideration to all the circumstances which have been just noticed ; as we are satisfied, from ample observation, that change of climate has not hither- to been productive of all the benefit which it is calculated to effect, — nay, that it has often done positive mischief, chiefly on account of the incon- siderate and injudicious manner in which it has too generally been prescribed and carried into effect We shall now proceed to give some account of the individual places in this and other coun- tries which have been chiefly resorted to by in- valids, on account of the mildness or other pecu- liarities of their climates. English Climates.—The great desideratum in this country is to find a mild climate and sheltered residence for our pulmonary and other delicate invalids during the winter and spring: we shall therefore direct our attention principally to this point Our warmest winter residences in England are mostly found on the southern and south-western shores; indeed it is their vicinity to the sea which in a great degree renders them warmer than the inland parts in their respective vicinities. The mild region of England admits of a na- tural division into four districts or groups, each Vol. I. —56 having some peculiar features in its climate which characterise it and distinguish it from the others, both as regards its physical and medical qualities. These are—- 1. The south coast, comprehending the tract of coast between Hastings and Portland Island, including the Isle of Wight; 2. the south-west coast, from the latter point to Cornwall; 3. the district of the Land's End,- and 4. the western group, comprehending the places along the bor- ders of the Bristol Channel and estuary of the Severn. Sonth Coast.—The superiority of the climate of this district exists chiefly during the months of December, January, and February. In March the temperature of this coast, and that of the in- terior, (e. g. the vicinity of London, which we select as a convenient point of comparison,) is nearly the same. In April and May, the tem- perature of the interior rises above that of the coast and continues higher, though in a less ratio, through the summer months. In October the mean temperatures are again equal, and in No- vember, that of the coast begins to exceed the in- terior. The only places on the south coast which we consider deserving of particular notice, are, Undercliff in the Isle of Wight, and Hastings and Brighton on the coast of Sussex. Undercliff is decidedly the most sheltered and warmest of these places, and it has moreover this convenience over most of our other winter resi- dences, that it also affords a good summer climate, a circumstance of considerable importance to many invalids. Unfortunately, at present, few can avail themselves of the advantages of this sheltered district, from the want of the necessary accommo- dations. [Of late, the accommodations for in- I valids have been greatly increased. (Sir James Clark, The Sanative Influence of Climate, p. 134. Lond. 1841.) The Isle of Wight presents a great variety of healthy and beautiful sites for different classes of valetudinarians, both as winter and summer residences.] Hastings follows Undercliff in point of shelter and warmth during the winter and spring months. Its situation at the base of a range of steep hills, which protect it in a considerable degree from the north and north-east winds, render it a milder and more sheltered residence during this season than the other parts of the coast of Sussex. [St. Leonard's is about a mile to the westward of Hastings. The climate of the two places is almost identical; — but the accommodations are much better at the former. (Sir James Clark, op. cit. p. 126.)] Brighton differs materially in the character of its climate from both these places. It is more ex- posed to northerly winds, but the atmosphere is drier and more bracing. While inferior to Un- dercliff and Hastings as a residence in diseases of the respiratory organs accompanied with much irritation, it offers advantages over both to invalids of a relaxed and nervous habit who are not very excitable. Autumn is the season during which the climate of this place possesses the greatest ad- vantages ; and even to the end of December it is one of the mildest climates in our island, and most favourable for a large class of invalids ; more espe- 442 CLIMATE. cially for cases in which a relaxed state of the system is a leading feature. Invalids who select the coast of Sussex as their winter residence, might find it advantageous to pass the autumn at Brighton and the winter at Hastings. Sonth-west Coast. — The winter climate of the south coast of Devon has long been noted for its mildness. The temperature of its more shel- tered spots during the months of November, De- cember, and January, (when the difference is greatest.) is, in the average, about five degrees higher than that of London during the same pe- riod : whereas, on the south coast, the difference scarcely exceeds two degrees. This superiority of temperature over London at both places, occurs chiefly during the night; though the days are proportionably warmer, and the temperature more steady on the south-west than on the. south coast. In making this comparison, however, between these two districts, it is right to observe that Un- dercliff is not taken into the account for want of sufficient data. Various places on the coast of Devonshire are held in repute on account of the beneficial effects of their climate, more especially in pulmonary diseases. The principal of these are Torquay, Dawlish, Sidmouth, and Exmouth. Salcombe, the Montpelier of Huxham, is unquestionably one of the warmest spots in our island during the win- ter ; but it possesses few accommodations, and its sheltered climate is confined to too small a space to admit of its ever acquiring importance as a re- sidence for invalids. Indeed, this limited character of the climate is the great defect of all the places on this coast, with the exception of Torquay. Here the invalid has the advantage of a consider- able tract of sheltered country, some part or other of which will afford a protected ride or walk, in whatever direction the wind blows. Torquay is superior in this respect to every place in our island. Its position, also, on the southern decli- vity of a range of pretty steep hills, composed chiefly of calcareous rocks, renders it compara- tively dry. Hence, while Torquay possesses all the advantages of the climate of this coast, its chief disadvantage (humidity) is felt in a less de- gree than elsewhere. Laud's End.—The only place in this district deserving particular notice is Penzance, which has long been frequented by invalids on account of the mildness of its winters. Penzance has a very peculiar climate, which depends on its almost peninsular situation at the south -western extremity of the island. A remarkable equality in the dis- tribution of the temperature throughout the year, and throughout the day and night, is a striking In other respects the climate of the Land's-End does not stand so high in a medical point of view. It is very humid ; the quantity of rain which falls annually at Penzance being nearly double that which falls in London, and the number of rainy days much greater. This district is also proverbial for the frequency and violence of its gales; and Penzance, owing to its total want of shelter from the northerly and easterly winds, is colder during the spring than either Torquay or Undercliff. Hence it is that although Penzance possesses a decided superiority over all the other situations in our island in the mildness and equability of its winter climate, its humidity, exposed situation, and liability to winds, render it inferior to several other places as a residence for invalids. I In giving the above as the character of the cli- mate of the Land's-End. we are fully borne out ! by the experience of Dr. Forbes of Chichester, who i resided there for some years, and to whose excel- I lent Medical Topography of this district we are i chiefly indebted for our information respecting its j climate, and the influence of this on disease. Flushing, a small village in the vicinity of Fal- mouth, is the only other place in this district de- serving notice. The position of Flushing differs from that of Penzance only in being somewhat protected from the north and east winds by a low range of hills which rises immediately behind it But the place is extremely confined, and deficient in accommodations for invalids. Before quitting the south-west coast and Land's- End, it is proper to remark, that, though varying somewhat in degree at different places, the predo- minant character of the climate is that of softness and humidity ; on the system generally, it has a soothing but relaxing influence. From this character of the climate of the whole south-western coast of our island, it will be at once understood that it is most suitable for the irritable and inflammatory li ibit. and least so for the re- laxed nervous constitution ; that in the dry, irri- tated conditions of the mucous membranes, with a parched state of the skin, it will prove benefi- cial ; whild in the morbid states of the same mem- branes, accompanied with copious secretion, or when there exists a disposition* to profuse dis- | charges of any kind, it will prove injurious. Even I many of those cases which are benefited by a j temporary sojourn, would be injured by a perma- nent residence in this district. The climate, in- deed, possesses qualities of so marked a kind, that when it ceases to do good, it generally begins to do harm; hence it will seldom be prudent much less advantageous, for the invalid who has passed the winter and spring on this coast, to prolong his residence through the summer ; he will in g.-noral character of this place. In this respect indeed, | do well to betake himself to a drier and more the climate of Penzance is superior to that of the south of Europe, and the only climate which we have examined that excels it is that of Madeira. This peculiarity of the climate of Penzance will be shown at once by comparing it with that of London, where the difference between the warm- est and coldest months is 26°, while at Penzance it is only 18°. In winter, Penzance is, on an ave- rage, nearly six degrees and a half warmer than London during the night, and but little more than three degrees during the day. bracing air, especially if he intends to return the succeeding winter. Unless the circumstances which we have just pointed out respecting the character and effects of this climate, and the nature of the constitution and diseases of the invalid, are kept in view, little benefit will be derived from a residence in Devon- shire. West of England.— Clifton, the only place in the western district which we deem it necessary to notice, has several local advantages, and pos- CLIMATE. 443 sesses the best climate in the part of the country where it is situated. Compared with that of the south-west coast, it is more exciting, more bracing, and drier, but not so mild. It is therefore less suited for pulmonary and other diseases, accom- panied with much irritation, and with a tendency to inflammation. On the other hand, it is better adapted to invalids of a relaxed, languid habit; and is also very beneficial in many cases of dys- pepsia, in affections of the mucous membranes with much secretion, and in the scrofulous affec- tions of young persons. In making a selection among these, which we consider the best winter climates in our island, in any particular case, we must consider well the character of the patient's disease and the nature of his constitution, before we venture to decide upon the situation best suited to him. But by attention to these points, and to the qualities of the different climates, which we have endeavoured to state as clearly as the nature of the subject and the extent of our knowledge would admit, the medical practitioner will not err greatly. In order, however, to illustrate the subject further, we shall add a few more particular observations on the practical application of English climates to disease. The climate of the south coasts of Devon and Cornwall will be found very efficacious in sooth- ing an irritated and irritable state of the respira- tory organs, and of the mucous surfaces generally; as in chronic inflammation of the fauces, and of the laryngeal, tracheal, and bronchial membrane, of a dry irritable character, or at least accompa- nied with little secretion, and highly susceptible of increased irritation from sharp, dry winds. In dyspepsia depending chiefly on an inflammatory condition of the mucous membrane of the diges- tive organs; in disorders of the uterine system, arising from a similar condition of the parts, giving rise to dysmenorrhoea; also in the numerous ner- vous affections originating in the disorders of these two influential classes of organs, this climate may be confidently recommended, and will generally be found beneficial. To these may be added cuta- neous diseases of a dry, irritable character. On the other hand, in disorders of the same organs and parts attended with passive congestion, or very copious secretion; in dyspepsia from an ato- nic state of the stomach, and in disorder of the uterine system, accompanied with an excessive flow of the catamenia, or leucorrhsea; and, in short, in all diseases attended with a relaxed state of the system generally, benefit is not to be ex- pected from the climate of the south-west coast; more especially if the invalid prolongs his resi- dence beyond a few months. The climate of Clifton, as has been already remarked, will prove more favourable in the cases last referred to. Brighton also presents an excellent autumnal climate for such invalids, and to persons of little constitutional sensibility offers a good residence throughout the winter, provided the more sheltered situations be selected. Hastings is a residence better adapted to invalids suffering from pulmo- nary irritation. During the spring months, that is, after March, any dry sheltered situation in the milder districts of the interior we believe to be superior to the south coast, with the exception of Undcrclifl*. After this survey of the best winter climates in England, it may be expected that we should take some notice of our more salubrious summer resi- dences. On this subject, however, it is not neces- sary to go into detail, as there is no lack of healthy situations to which our invalids i|nay repair with advantage during this season. In the selection of a summer, as of a winter residence, the same cir- cumstances require attention, both as regards the character of the climate and the nature of the invalid's disease. The milder and more sheltered situations must be chosen, even during this season, for delicate and very sensitive invalids; while for the relaxed and enervated, and those possessing less sensibility, the bracing air of the higher arid drier localities will prove more suitable. To a large class of invalids our sea-side watering places offer a variety of excellent situations; and for those cases in which sea-bathing promises benefit, they deserve a preference over the interior, espe- cially during the latter part of the summer and autumn. Several of our inland watering places, independently of the advantages to be obtained in many cases from the use of their mineral waters, afford good summer climates ; and, indeed, some of them, more on this account than any other, have become places of fashionable resort. Among these we may mention Malvern, Cheltenham, Leam- ington, Tunbridge Wells, Matlock, Buxton, &c. When the intention is to use the mineral water, the climate must of course be made subservient to this object; but when a choice of waters is ad- missible, it is of importance to many invalids that the climate selected also be suitable to them. In general it will be advantageous to invalids who have taken a course of mineral waters at any of those places, to pass the autumn by the sea-side, as at some of the driest places on the south, or south-east coast. In the greater number of cases in which travelling is borne without inconveni- ence, several changes, or a succession of short journeys, will be more beneficial than a residence at any one place during the whole season. It is remarkable how such repeated changes, with fre- quent gentle exercise, especially on horseback, renovate the constitution enfeebled by disease, enable it to overcome many chronic affections, and contribute to the restoration of permanent health. But we shall have occasion to recur to this subject [The Island of Bute, which lies in the Frith of Clyde, about 18 miles below Greenock, resembles, in the character of its climate, the south-west of England and France, and the Channel Islands, although its temperature is considerably lower than any of these. As a winter residence for in- valids, it is considered by Sir James Clark, (op. cit. p. 170,) to hold out considerable advantages to that class for whom a soft, equable, but rather humid atmosphere is indicated. Cove, on the island of the same name in Cork harbour, has one of the mildest climates in Great Britain, corresponding in general characters, and its influence on diseases, with the south-west of England, and other similar climates. In equability of temperature, Cove is surpassed by few places. Recent observations have shown, that the mean difference of temperature of the days and nights rarely exceeds four or five degrees, and often, in 444 CLIMATE. the winter months, does not exceed one degree. The town is completely sheltered from the north wind, and, from its southern exposure, receives the full influence of the sun and the southern breeze. (Stokes on Diseases of the Chest, 2d Amer. edit. p. 4^7 : Philad. 1844.)] Before commencing our review of foreign cli- mates, the islands of Guernsey and Jersey re- quire some notice, as they are occasionally resort- ed to by invalids from this country. The climate of these islands resembles in its general charac- ters that of the coast of Devonshire; it is some- what warmer but not more steady, and is more exposed to high winds. Those from the south- west, prevail during the autumn and winter, while those from the north-east often continue for weeks together during the spring, producing the same unpleasant effects on invalids which arise from them in this country. The climate is found by experience to be beneficial in the same diseases, and in constitutions of a similar character, as that of our south-west coast; the observations there- fore formerly made relative to the class of invalids that may expect to derive advantage from the lat- ter, apply equally to persons who may be sent to Jersey, which, of the two islands, is in all respects the best suited for invalids. The summer climate of these islands is delightful. Fokeigx Climates. — The climate of the South of France has long been held in repute, but all the southern provinces of that country are far from possessing the same climate; those situated on the eastern frontier being very differ- ent in this respect from those, on the western. It is highly important, as we shall presently show, to attend to this distinction in recommending the south of France as a place of residence for in- valids. South-west of France.—We comprehend under this division the tract of country which extends from Bordeaux and Bayonne to Tou- louse. The transition from the climate of the south- western shores of our own island to that of the south-west of France is easy and natural, inas- much as they exhibit a striking similarity in their general characters. Taking the south-west of France generally, the mean annual temperature is only about 4° higher than that of the south- west of England. Both climates are soft and rather humid, and agree, and disagree, generally speaking, with diseases of the same character. Pau is the only place in this district of France which we deem it necessary to notice particularly. This little town, which has been a good deal fre- quented of late years by invalids from this coun- try, is pleasantly situated at the base of the Pyre- nees; and when its close vicinity to that range of lofty mountains is considered, it certainly pos- sesses a far milder winter and spring climate, and is much less subject to high winds and extensive transitions of temperature than might be expect- ed. One remarkable circumstance in the charac- ter of its climate is the mildness of the spring, and its comparative exemption from sharp cold winds during that season. In this respect it bears a very favourable comparison with the climates of the south of Italy. While Pau is 6° colder than Rome during the winter, it is only 2$° colder in the spring. Compared with the warm- est parts of England, the same superiority of its spring climate holds good. Penzance during the winter months is 3° higher than Pau, but 5° lower in the spring. This mild character of the spring constitutes the great advantage of the climate. Pau is also very free from fogs, and possesses a dry soil. Its chief fault is the un- steadiness of its temperature. It may however be considered, upon the whole, the most favourable residence for invalids in the south-west of France, as far as we have had the means of judging. The difference between the climate of Pau and that of the best situations in England is not great. It is drier and warmer in the spring, and the northerly winds are much less trying to invalids than in this country. One advantage possessed by it is its vicinity to the delightful watering places among the higher Pyrenees, which offer to the invalid who has passed the winter at Pau a healthy sum- mer climate without the inconvenience of a long journey. South-east of France.—Under this division we include that extensive tract of country which stretches along the shores of the Mediterranean, from Montpelier to the banks of the Var, the boundary stream between France and Piedmont The climate of this district is warmer and drier, but more irritating and exciting than that of the south-west. It is also subject to sudden vicissi- tudes of temperature, and to frequent harsh, cold winds. This great liability to cold piercing winds, more especially the north-west, (mistral,) which often continues to blow with considerable force for many days together, renders the whole of this country an improper residence for patients suffer- ing under, or peculiarly disposed to inflammation or irritation of the respiratory organs. We con- sider the custom, therefore, which has long pre- vailed, of sending consumptive patients to the south of France, a grievous error; an error which the obvious character of the climate, and the re- sult of ample experience of its effects, should have long since corrected. There may be con- stitutions having a tendency to tuberculous dis- ease, which might even derive some benefit from a temporary residence in this climate ; but when tubercles already exist in the lungs, it will cer- tainly prove injurious. After this account of the climate and its effects on phthisical patients, (the cases which have been chiefly sent thither,) it will be unnecessary to say much of the different places in this district which have been most frequented by invalids. We shall, however, notice the principal of these briefly. Montpelier.—This place has now so completely j lost the character which it once possessed as a mild climate, that it may suffice to remark here, that a more improper residence could scarcely be selected for a person disposed to pulmonary dis- ease. Its high, exposed situation renders it liable to all the evils of this climate in a remarkable de- [ gree ; and it is, moreover, well ascertained that pulmonary inflammation and phthisis are among the most prevailing diseases of the place. Marseilles—Although less exposed than Mont- pelier, this is an equally improper residence for I consumptive invalids. From the manner in which CLIMATE, 445 the environs of Marseilles are divided into small properties, surrounded with high walls, the invalid has no means of taking proper exercise, or of breathing country air ; and without these, con- sumptive invalids can derive little advantage from any climate. For cases likely to benefit by a dry sharp air, Marseilles forms a good winter resi- dence. It is said to prove particularly favourable to persons who have suffered from intermittent fever. Hycres possesses the mildest climate in the whole of this district, and this advantage it owes chiefly to its sheltered situation at the base of a range of hills which protect it, in a considerable degree, from northerly winds. The country also around this little town differs in its character from that of Provence generally (which comprehends the larger portion of the district now under consi- deration). The hills here present the appearance of verdure, being covered with shrubs, many of them evergreens, affording a pleasing contrast to the bare and rugged mountain masses which form so striking a feature, and compose so large a por- tion of Provence ; a country which very generally disappoints the expectations of the traveller, and especially of the invalid, whose hopes have been raised high respecting the beauty of the south of France. The extensive orange gardens which flourish under the immediate shelter of Hyeres, and the verdure of its hills, afford evident proofs of the amenity of its climate, while by experience it is known to be one of the most favourable resi- dences for invalids in this part of France, — cer- tainly the best with which we are acquainted. Nice.—This place has long been celebrated for the mildness of its climate, and continues to form the favourite resort of a numerous class of invalids, both from this and other northern countries. Al- though situated in the same line of coast as Pro- vence, Nice is superior to it in several respects. In the general qualities of its climate it certainly resembles that of the south-east of France; but it has some important local advantages over the best parts of that country. By ite steep and lofty range of mountains it is protected from the northerly winds, and especially from the mistral, which we have stated to be so prevalent, and which expe- rience proves to be so injurious to delicate invalids, in Provence. This circumstance gives a compara- tive degree of softness to the climate : but it is still rather exciting. Nice is not exempt from cold winds, especially during the spring; indeed, the prevalence of these constitutes one of the principal objections to the climate of this place in pulmonary diseases generally. For consumption, even in its earlier stages, we consider Nice an un- favourable situation, in a very large proportion of cases. In bronchial diseases of the dry irritable character, it is also prejudicial; and in dyspepsia, depending on an irritated or inflammatory condi- tion of the mucous membrane of the stomach, it is equally so. So decidedly, indeed, is this the case, that when such a state of the digestive or- gans exists, the invalid will derive little benefit from a residence at Nice, whatever may be his disease. Though warm and dry, the climate is ill suited to irritable habits. With languid, torpid constitutions, on the other hand, it agrees well. In the scrofulous affections of young persons pos- 2s sessing this character of constitution, it produces the best effects; as it does in chronic bronchial disease accompanied with copious expectoration, and in what has been termed humoral asthma. In chronic rheumatism it is found very beneficial ; and in deranged health from various causes, in which a dry, warm, and rather exciting climate is indicated, advantage will be derived from a winter spent at Nice ; provided always that the state of the digestive organs which we have adverted to does not exist. In consequence of the tendency of the climate to aggravate and even excite gastric irritation, a more abstemious diet is requisite for invalids than in England. The summer at Nice is too hot for any class of invalids. [ Villa Franca, situate on the southern base, or rather declivity of a steep and lofty range of moun- tains, and having a beautiful bay extended before it, is immediately to the eastward of Montalbano. It corresponds in its general character of climate with Nice ; than which, however, it is said to be drier and somewhat warmer. Menton is described as a very retired spot, about 14 miles from Nice, on the Genoa road; and San Remo, still farther, is even more protected from easterly winds ; but the accommodations at those places are not good. (Sir James Clark, Op. cit. p. 214).] Italy.—The climate of the south of Italy differs little in actual temperature from that of Provence and Nice, but it is softer, more humid, and less exciting. On the other hand the sirocco, which is scarcely felt at the latter places, forms an objec- tion to the Italian climate, though this objection is not of much weight during the winter. The only places which we consider deserving of notice as winter climates in Italy, are Pisa, Rome, and Naples. The climates of Pisa and Rome resemble each other in their general qualities. Rome is some- what warmer in the winter. It is also drier than Pisa, though more humid than Nice and the parching climate of Provence. About one-third more rain falls at Rome than in the latter country, and the number of rainy days is considerably greater. Taking into account all the qualities of the climate of Rome, we consider it one of the best of Italy : to the invalid capable of taking exercise in the open air, it affords advantages over both Naples and Pisa. Patients, on the other hand, who can bear little exposure to the air, and who must therefore confine themselves to the most sheltered situations, will find in the Lung'Arno in Pisa, a residence possessing advantages, perhaps, over every other place in Italy. Naples differs somewhat in the character of its climate from both the last-named places. Inde- pendently of the effect which its immediate vici- nity to the sea may have in modifying the climate, it is more subject to winds, and the air is more exciting than that of Pisa or Rome. As a resi- dence for invalids labouring under pulmonary irritation, or chronic rheumatism, it is inferior to both; nor are we aware of any cases in which it ought to be considered a more favourable climate. The beauty of the scenery around Naples, how- ever, and the gaiety and excitement of the place and climate altogether, prove very attractive to strangers generally, and render it a very agreeable winter residence for persons who visit Italy rather 446 CLIMATE. as a recreation than for the removal of actual dis- ease. The diseases in which the climate of Italy proves most beneficial, are chronic bronchitis and rheumatism. We have, in particular, observed many decided examples of the beneficial effects of a residence at Rome in both these diseases. But it is still more in the numerous cases of deranged health which scarcely admit of being defined, though well known to the medical practitioner, that a tour and winter spent in Italy will prove beneficial. Such persons need not be limited to any particular situation, but may, with proper cau- tion, visit the different places frequented by stran- gers in the south of Italy, and that even with greater advantage to their health than if they had remained stationary at any one of them. These observations have reference to the cli- mate of Italy during the winter and spring, that is, from October till May or June. To such as are under the necessity of remaining in that coun- try through the summer, the baths of Lucca, Sien- na, and the vicinity of Naples afford the coolest residences. There may be several situations on the shores of the Mediterranean which have climates equal, and perhaps superior to those which have been mentioned. Malaga has been particularly men- tioned to us as possessing a very mild winter cli- mate ; but our information respecting the south of Spain is too imperfect to enable us to speak positively on this subject. And even were the climate of that country superior to that of the south of Italy, the want of proper accommodations and the various comforts which are as necessary to the invalid as climate, forms an insuperable ob- jection to them as places of residence for delicate English invalids. The Mediteraneax islands do not merit much notice. Some parts of the coast of Sicily afford a pretty good winter climate; but here again the difficulty of obtaining the necessary comforts, and even conveniences of life, renders them almost useless to English invalids. This objection, however, cannot be made to Malta, the only island in the Mediterranean be- longing to this countiy. All the wants of the invalid may be supplied here, and the packets which are established between this place and Eng- land afford the means of reaching it conveniently. But, unfortunately, the climate of Malta has little to recommend it to any class of invalids, and least of all to such as suffer from pulmonary affections. The arid nature of the soil, the quantity of im- palpable dust which is suspended in the atmos- phere whenever the weather is dry, the currents of cold air to which the capital (the residence of in- valids) is subject during the winter, and the fre- quent and heavy rains which prevail during the same season, render it an unsuitable residence for patients of this class. It may not be irrelevant to mention also that phthisis carries off a large pro- portion of the inhabitants of Malta, constituting nearly one-tenth of the whole mortality, according to Dr. Hennen. Indeed, the full and satisfactory information respecting the medical topography of Malta, supplied by this gentleman, affords more than sufficient grounds for excluding it from the list of climates which promise any advantage to phthisical patiento. We are not, indeed, aware of any class of invalids likely to derive much advan- tage from the winter climate of Malta, and we are not acquainted with any to whom its summer cli- mate would not prove injurious.* Atlantic climate. — The climate of the Northern Atlantic in the temperate latitudes is more steady than that of the Mediterranean, and imparts a similar character to the climate of its islands. Various groups of islands scattered over this ocean, between the 28th and 38th degrees of latitude, having been praised for the excellence of their climate, and occasionally frequented by in- valids in consequence, deserve some notice in this place. The Azores, the Madeiras, and the Canary Islands in the Eastern, and the Bermudas and the Bahamas in the Western Atlantic, have all been recommended as suitable residences for persons requiring a mild and equable climate, and more especially for consumptive invalids. As our information respecting the climate of Madeira is the most complete, we shall notice it first, with the view of making it a standard of comparison in estimating that of the other islands. Madeira. — The minute and careful observa- tions of the late Dr. Heineken and of Dr. Renton, for a series of years, have afforded us sufficient data to form an accurate estimate of the climate of this island ; and although our materials for enabling us to judge of the other Atlantic islands are much less complete, they leave little doubt in our minds that Madeira is superior to any of them; while it affords conveniences in other respects as a residence for invalids possessed by none of them. The height of the central ridge of mountains which compose the greater part of this island, al- though it may detract somewhat from its warmth during the winter, contributes greatly to temper the heat of its summer. It gives Madeira the advantage of a cool land-breeze during the night, which, alternating with a refreshing sea-breeze in the day, moderates the summer heat in a very material degree ; while the trade winds which prevail at this season in the latitude of Madeira, contribute also to its coolness and salubrity. The invalid, moreover, by choosing for his summer residence an elevated situation in the interior, finds a climate considerably cooler than that of Funchal which is situated on the sea-shore and affords the best winter residence. Comparing Madeira with the south-east of France and Italy, we find that, although its mean annual temperature is only about six degrees high- er than that of these places, this temperature is very differently distributed throughout the year, the range being far less at Madeira than in the most favoured spots in the south of Europe. Thus, while the winter is twelve degrees warmer than in Italy and France, the summer is five degrees cooler ; and while the mean annual range at Ma- deira is only fourteen degrees, it is nearly double this at Pisa, Rome, Naples, and Nice. In the equable distribution of heat throughout the year, it possesses a similar superiority over the same places; for example, while the mean difference of * We refer thos.- who desire to examine the facts upon which the a hove diameter of the climate of Malta rests, t" Dr. Henjun's Sketches of the Medical Topography oftht Mediterranean, &c. [See, also, Sir James Clarke op. cit. p. 241.J CLIMATE. 447 temperature of successive months at Madeira is . the southern coast of St. Michael's, during the only two degrees, at Rome and Nice it is four, period from Dec 1838 to April 1839, was 60°.9, and at Pisa and Naples five degrees. | with a mean range of 3°.6. The mean out-door In the progression of temperature during the temperature, during the same time, was 60°.10, day, it maintains the same superiority ; the mean i and the mean daily range 7°.8. The highest range for twenty-four hours being ten degrees by ' point to which the thermometer rose in the shade, the register thermometer, while at Nice it is nine j between eight o'clock in the morning and ten at degrees, at Rome ten degrees, and at Naples thir- night, was 76° ; and the lowest point to which it teen degrees by the common thermometer. In < sank was 51°. The average out of doors was steadiness of temperature from day to day, (a very ! not, however, taken with the register thermome- imporlant quality in a climate,) Madeira excels all ter; but it approximates the truth. Sir James those places greatly. There is also a considerable I Clark (op. cit., p. 288,) is of opinion that a change difference in respect to the dryness of the two cli- from the Azores to Madeira, and from thence to mates. Nearly the same quantity of rain falls at | Teneriffe, would prove, in many cases, more bene- Madeira as at Rome; but there are only seventy- ' ficial than a residence during the whole winter in. three days on which any rain falls, while at Rome . any one of those islands.] there are one hundred and seventeen days. The Bermudas.—This numerous cluster of small rain at Madeira also falls at more regular seasons, I islands is in the same latitude as Madeira, and chiefly in the autumn, the atmosphere being gen- ! differs little from it in the mildness of its winter erally dry and clear for the remainder of the year, j climate. From the stormy character of the West- The annual range of atmospheric pressure is ; tern Atlantic, however, these islands are much very small, which is the case also at Rome and more liable to high winds in the winter than Ma- Naples. I deira, while their low character and arid rocky From this comparison, the superiority of the soil render them extremely hot during the sum- climate of Madeira over that of the south of Eu- mer, and quite improper at this season for the resi- rope will be at once seen. We shall have occa- , dence of such invalids as are likely to be sent from 6ion hereafter to notice their comparative influ- ence on disease. Canary Islands.—These rank next to Ma- deira in point of climate. They are somewhat warmer; the mean annual temperature of Fuu- chal, the capital of Madeira, being 65°, while that this country. Bahamas.—This is another and much more extensive group of low islands, further south than any of those which have been mentioned, being only just beyond the limit of the tropics. The climate of thl Bahamas has not much to recom- of Santa Cruz, the capital of Teneriffe, is nearly . mend it. The winter and spring are considerably 71°. This excess of temperature, however, is not equally distributed over the whole year, the difference between the winter temperatures at these two places being considerably less than between their summer temperatures ; while Santa Cruz is 7° warmer than Funchal in summer, it is only 5° warmer in winter. The temperature is also more equable throughout the year at Madeira than at Teneriffe ; the difference between the mean tem- perature of summer and winter being 9° at the former place, while it is 12° at the latter. The want of sufficient materials prevents us from com- paring the climate of Teneriffe more minutely with that of Madeira. It seems probable, how- ever, that when we are better acquainted with the climate and topography of Teneriffe, we may find it a favourable winter residence. But whatever may be the merits of its climate, it is at present very deficient in the other requisites necessary to render it a suitable abode for delicate invalids. The Azores, or Western Islands, as they are sometimes called, lie about 5° north of Ma- deira, and considerably more to the westward. In their external characters these islands resemble Madeira and the Canaries. We have not had the means of making ourselves sufficiently ac- quainted with the temperature of the Azores to speak very positively on the subject The climate appears to be mild but somewhat humid ; less warm than Madeira during the winter, and more oppressive during the summer. They certainly possess no advantages in point of climate over Madeira, while they afford few of the conveniences which that island offers to invalids. [The mean in-door temperature of a room with cooler than the same seasons in the West Indies, while the temperature of the summer and autumn is nearly the same as in those islands. During the winter the temperature is subject to rapid and considerable vicissitudes, and cold, harsh, north- erly winds are not unfrequent The close vicinity of the Bahamas to the North American continent no doubt has the effect of rendering the climate less equable than it otherwise would be, judging from what we know of insular climates generally in the same latitudes. We may safely dismiss these two western groups with this brief notice ; as from the charac- ter of their climates, their great distance from England, and the few local advantages which they possess, they are never likely to prove beneficial as a residence for invalids from this country. They are better suited, in point of climate, and, more conveniently situated, particularly the Bahamas, as a temporary retreat for the inhabitants of the islands which we are now to notice. West Lndies. — Although these Islands are not often resorted to by real invalids, yet there seems to exist, even among the profession, a vague idea that they afford a preferable climate to that of any of the places which we have noticed. That this opinion has been formed from an im- perfect knowledge of the nature and effects of a tropical climate, we shall endeavour to show. The mean annual temperature of the West- India Islands, near the level of the sea, is about 80°, and during the six months which include the winter season the temperature is only 2° lower. Now it will be readily admitted that few invalids are likely to be benefited by so high a out fire, carpet, or curtains, in Villa Franca, on , temperature, more particularly when continued, 448 CLIMATE. almost without sensible variation, night and day. The extreme annual range in the West Indies does not exceed 20°, while the mean daily range throughout the yeftr is only 6°. But it is not so much the actual degree of temperature of a trppi- cal climate, as its unceasing and unvarying character, which oppresses and exhausts the in- valid, more especially in cases where there exists a disposition to symptomatic fever. [Moreover, it appears from the British Army Reports, that nearly twice as many cases of con- sumption originated among the British troops in the West Indies as at home : twelve per thousand of the aggregate strength of the troops serving in the West Indies being attacked annually, whilst of the Dragoon Guards, serving in Great Britain, the ratio is only 6£ per thousand. The disease, according to the same reports, is even of more frequent occurrence among the black than the white troops. (Sir James Clark, op. cit., p. 303.)] From this brief account of the climate of the West Indies, it is evidently an improper one, ge- nerally speaking, for consumptive invalids, who, nevertheless, are frequently sent thither. The uniformly high temperature, and almost cloudless skies which afford no shelter from the direct rays of a tropical sun, preclude invalids from taking exercise in the open air, the principal object for which they are generally sent abroad. There is no twilight to compensate for the heat and glare of the day, and the nights are too ht>t to admit of refreshing repose. When we add to the fore- going evils of climate the many privations, dis- comforts, and annoyances which are almost in- separable from a temporary residence in these islands, and the still more weighty objection derived from the experience of medical men who have resided there, we may consider the question of the propriety of sending patients labouring un- der consumption to the West Indies as finally set at rest. The concurrent testimony of all the me- dical men whom we have consulted on the sub- ject, and whose opportunities of judging were ample, establishes the fact that consumptive cases sent thither from this country proceed much more rapidly to a fatal termination than in temperate climates. Notwithstanding what has just been stated re- specting the climate of the West Indies and its influence on consumption, we are not prepared to say that some, nay, many cases of deranged health, of a different nature, might not be bene- fited by passing a few of the less sultry months (from November to February) in that climate ; more especially if the invalid possesses the means of enabling him to spend the greater part of his time on the water, merely visiting some of the more healthy islands occasionally. The remark- able revolution effected in the distribution of the circulating fluids, and the immense increase in the secretion from the cutaneous exhalente, ex- cited and steadily maintained by a high atmos- pheric temperature, and this continued without intermission for many months, or even years, is unquestionably capable of producing material and very important changes in the ani nal economy, and may therefore be made a powerful agent in the cure of chronic diseases. Calculous disorders are extremely rare in the West Indies, a circumstance which probably de- pends, in a great degree, on the abundance of the cutaneous secretion, by which the largest propor- tion of fluid is discharged from the system, and along with it some of those saline principles which constitute the chief ingredients of which urinary calculi are composed. A well known case has been recorded of an officer who was about to undergo the operation of lithotomy in this country : he was suddenly ordered to Jamaica, and after some time no calculus could be dis- covered in the bladder, nor were there any symp- toms of the existence of one. Aneurisms and diseases of the heart and large vessels are also rare, and the osseous deposits, which are so gene- rally found in the coats of the larger arteries in persons who die at an advanced age in cold climates, are said to be rarely met with in those who die at a similar age in the West Indies. Gout is not common, and rheumatism neither fre- quent nor severe. Reasoning on the above facts, we should expect that the climate of the West Indies would prove serviceable to persons labouring under what has been denominated the calculous diathesis, in which there is a constant disposition to renal irritation, and the formation of gravel, upon any material change of the weather, or any trifling derangement of the digestive organs. The func- tions of the skin in such persons are generally imperfectly performed, and it is not unreasonable to believe that the powerful action excited, and unremittingly kept up for some months, in the cutaneous exhalente might effect a permanent change in the constitution, and if followed up by warm clothing, daily friction, and a proper diet, might entirely destroy the disposition to the for- mation of gravel. Upon the same principle this climate also promises benefit to persons in whom we have either positive, or strong presumptive evidence that ossific deposits are forming in the arterial system, and laying the foundation of aneurism or diseased heart Reflecting on the powerful effect of a high temperalure on the vari- ous secretions, we think it not improbable that the further progress of such a morbid process might be checked by a timely removal to the West Indies, or any similar climate, and a re- sidence for a longer or shorter period there, ac- cording to the circumstances of the case. What has been already stated respecting the rare occur- rence of calculous disorders and diseases of the arteries in this climate, affords some grounds for such a conjecture; and it may be adduced in further support of it, that gout, a disease intimate- ly related in its nature and causes to both the preceding affections, is greatly relieved, and even entirely cured in many cases, by a change from a cold to a hot climate. This effect of climate has long been known. Van Swieten mentions the case of a gentleman who had almost entirely lost the use of his hands and feet from gout, and who, after a residence of nearly three years in the East Indies, returned perfectly free from disease, and continued so; and Haller relates the case of Lord de Poincy, who, when an old man, went to the warm American islands, and got rid of his gout and other infirmities. And such instances CLIMATE, 449 must have come under the observation of almost every physician. Scrofula is a very rare disease in the West-India islands, and there are many cases of scrofula in this country which we have little doubt would be greatly benefited, if not cured, by a temporary residence in that climate. The cases in which we should expect the greatest benefit are those in which the disease exists chiefly in the lymphatic glands in torpid constitutions. [United States.—For those of delicate lungs, it would appear, that St. Augustine, Tampa Bay, Pensacola, Mobile, and certain situations on the Peninsula of Florida, are the best situations, judging merely from meteorological registers: but, in all such cases, the extent of accommodation for the valetudinarian must be taken into account. The places on the eastern seaboard, especially, are exposed to frequent north-east storms, during which, however, the invalid must remain at home; yet there are few days during the winter when he cannot have the salutary revulsion which exercise in the open air is capable of effecting. Hence, any of these situations has a decided advantage over those of the northern and middle states. In the interior of Georgia, Florida, Alabama, or Louisiana, the same objections do not apply; and accordingly, they are often visited by the invalid during the winter, and with great advantage. During the summer, the wide extent of this country affords great choice of residence. The sulphur springs of Virginia, especially the red sulphur; and the warm, the hot, and the sweet springs, are often frequented. These are situate high above the level of the sea, and afford as great a change as difference of climate can easily effect During the summer, a tour may be made to any interesting region that is capable of exciting new impressions upon the mind; and, of late, favour- able attention has been directed to the northern lakes as a summer residence for invalids of the south ; and a tour to them may be of great advan- tage to those from every part of the country. (Prof. Drake, The Northern Lakes, a Summer Residence for Invalids. See also the writer's Ele- ments of Hygiene, 2d edit. Philad. 1844.) SatTHEHN Hemisphere___The climates of the southern hemisphere are calculated to exert the same sanative agency on the frame as those of the northern. From their situation south of the equa- tor, their seasons are the reverse of ours. August, September, and October, constitute the spring months; November, December, and January, sum- mer; February, March, and April, autumn, and May, June, and July, vjinter. Of the climate of certain portions of South America, we know something from the observa- tions of the navy surgeons more especially. It rarely happens, however, that invalids are sent thither for change of climate. Dr. Burrough re- sided four years in Lima, and did not meet with a single unequivocal case of phthisis, which ori- ginated there during that period ; although scrofula was not uncommon,—a fact which confirms the view of the distinctness of scrofulosis and tuber- culosis. He stated to Dr. Morton, (Illustrations of Pulmonary Consumption, p. 159: Philad. 1834,) that he knew many foreigners in consump- tion to be much benefited by a residence in Lima; Vox.. I. — 57 2 n * but that in every instance where they had been tempted to go farther south into Chili, the effect on their constitutions was fatal. The Cape of Good Hope is occasionally re- sorted to by invalids from India and England.— From the Army Medical Reports it appears, that the climate is at least as favourable to health as that of Great Britain. The troops are less sub- ject to diseases of the lungs at Cape Town, than in the other British colonies; and there is a smaller proportion of deaths from consumption than has been observed in our foreign stations, except the East Indies. Rheumatism is, however, very com- mon. The places chiefly resorted to by invalids from India and England at the Cape of Good Hope, are Rondebosch, about five, and Wynberg, about eight miles from Cape Town; at both of which places there are good accommodations. The climate of Australia is said to be remark- ably healthy. Europeans, enervated by a residence in India, are very much invigorated by a short re- sidence there. (Sir James Clark, op. cit. p. 336.)] We have now noticed the principal climates, both in our own and foreign countries, which have acquired the greatest reputation as places of resi- dence for invalids, and regarding which our infor- mation is sufficiently accurate to enable us to speak with much certainty. From a residence at one or other of these places, or at several of them in succession, all that climate can effect may, we believe, be obtained by the invalid whose disease admits of benefit from a change of this kind; provided always that the climate which is best suited to his disease and constitution be selected. In making this selection we must, in the present state of our knowledge, be guided chiefly by ex- perience ; for although an acquaintance with the physical characters of a climate is highly useful in enabling us to form a tolerably correct opinion respecting the diseases in which it will prove bene- ficial ; still, until we have had some experience of its effects, we can never be sure that our conclu- sions are correct; so complex is the subject of climate, and so many are the circumstances, some having reference to the agent and others to the subject, which require to be taken into account. We shall now state briefly the effects of climate on those diseases on which it has been found to exert the greatest influence. Pulmonary Consumption is the disease in which, from its supposed dependence on climate, and its being found to resist all other modes of treatment, this remedy has been more particularly had recourse to, and almost as the only remaining hope. This is not the place to enter into a full detail of the circumstances under which climate promises benefit in that disease. (See the article Pulmonary Consumption.) We may, how- ever, remark here, that climate, to be productive of real benefit, must be tried at a much earlier pe- riod in the progress of tubercular disease than it generally is. Such is the insidious manner in which consumption, in many cases, steals upon its victims, that it has too often stamped its indeli- ble impression on the vital organs ere the alarm is sounded, or climate or any other effectual means of treatment, have been seriously thought of. Be- fore we can reasonably hope to cure phthisis, we must take a much more comprehensive view of 450 CLIMATE. the padiology of that disease than we have hitherto done : in place of fixing our attention solely on the diseased state of the lungs, we must direct it to the morbid condition of the system,—to the tubercular cachexia in which phthisis has its ori- gin. As regards the application of climate to the disease, it is not, we believe, saying too much, when we state that consumptive patients are, for the most part, sent abroad one year at least, often several years, too late to derive any essential bene- fit from change of climate. During that peculiar state of deranged health which may often be observed to precede tubercular cachexia,* and during the existence of this mor- bid sUte of the constitution, before the disease has manifested itself in the actual development of tubercles in the lungs, change of climate forms a powerful adjunct to the other means best calculated for removing such a state of the system. When tubercles already exist in the lungs, the chances of cure are immeasurably lessened ; but even then climate affords one of our most valuable resources, and one which promotes the salutary action of all our other remedies ; and although our hopes of benefit under such a discouraging state of things must in general be faint, we believe the further progress of the disease may, in some cases, be thereby arrested. But such instances of success are no doubt very few, compared to the many which proceed unchecked in their course to a fatal termi- nation, in despite of climate and every other means which we can oppose to their progress. We would therefore beg to impress upon the minds of our professional brethren the urgent necessity of directing their attention to the earliest indications of this disease, seeing how utterly inefficient all our efforts are even to stay its fatal career, when so far advanced as to manifest itself to the com- mon observer. Until the tubercular affection of the lungs, which constitutes the essential character of what is commonly termed phthisis, is consi- dered in its true character, as the last stage of a disease,—as the result of a morbid state of the system, which in its progress might often be cured, but which in this its termination is scarcely to be remedied,—we must still continue as heretofore, little better than idle spectators of the ravages of a disease which destroys one-fourth of our popu- lation, and numbers among its victims a large pro- portion of the best and fairest of our youth. In proof of the correctness of our opinions re- specting the influence of climate on phthisis in its early and late stages, we shall give the experience of Dr. Renton, an intelligent and observing phy- sician, who has long practised at Madeira, and has had ample opportunities of watching the effects of that climate on phthisical invalids sent thither from this country. This gentleman has favoured us with notes of the cases which came under his own particular observation. From these we find that between the years 1827 and 1830, nineteen, patients labouring under confirmed phthisis arrived in Ma- deira, the whole of whom died; the greater num- ber on the island, the remainder after returning to * For an account of this affection sefi a work by the writer of this article, entitled "The Influence of Climate " &c., p. 315, Sec. 2(1 edit. Loud. 1830. 3d [euit. i,ond. 1641.] England. Oi thirty-three cases of incipient phthisis, which arrived during the same period, twenty-three are now at home, (June, 1830,) ap- parently in good health; two remain in the island, one apparently well, the other considerably better since his arrival, but still in a doubtful state; two died, one in the island, and another after leaving it: the fate of the remaining six is not known. We consider this statement as a satisfactory reply to those who doubt and cavil respecting the influence of climate; their opin- ions being formed in general from a few casta sent abroad at a period of the disease when no hope of benefit could be reasonably entertained. It is only by such numerical records as the above, that we can expect to arrive at accurate conclu- sions respecting the influence of any means of cure in a disease, which will prove fatal in a very large proportion of cases, under any circumstances. The result in the first series of cases is nothing more than every one would expect who is ac- quainted with the nature of phthisis, and knows the state of the lungs in what generally passes under the name of confirmed consumption. But while Dr. Renton's experience of the effects of the climate of Madeira shows the inutility of change of climate in the advanced period of phthisis, it holds out considerable hopes from the adoption of this measure in its early stages : of thirty-three cases of incipient consumptions, twenty-four were apparently cured. Such a ratio of success, we have reason to believe, has never before been observed among consumptive invalids sent to Madeira, and for this plain reason—that they were rarely sent till the disease was too far advanced to admit of recovery. Dr. Renton remarks in his communication to us, " With respect to the inva- lids sent out, they have been very different foi the last two or three years from those sent out for- merly." We have the satisfaction of thinking that we have contributed, in some degree, to this i favourable result, by our appeal to British physi- cians in the work already referred to; and we shall be happy to find that the striking proof of the truth of our former remarks, now recorded, induces our professional brethren to pay still more attention to this subject. Of the Atlantic Islands, Madeira; in Italy, Rome and Pisa ; and in England, Torquay and Undercliff, afford the best climates for consump- tive cases. [Sir George Lefevre (Thermal Com- fort, Amer. edit. p. 39 : New York, 1844) recom- mends Valentia, in Spain. In the United States, St. Augustine, Savannah, Mobile and Pensacola, on the sea-board, are often visited; and occasion- , ally the interior of the peninsula of Florida, Ala- bama or Louisiana.] In stating these places to be the most favourable residences, we beg to be understood as referring to the winter chiefly. Italy, during the summer, is decidedly injurious to the phthisical invalid ; and those who have passed the winter in the milder climates of England should in general seek a more bracing air in summer, such as that of Mal- vern, or even some of the more elevated and drier districts of our island; or, what would be still better, they might in the course of this season change from one place to another, taking cure always that no place was visited possessing a CLIMATE. 451 climate decidedly hostile to their particular state of health. Such frequent changes of residence, when judiciously conducted, and combined with exercise on horseback, and a regimen suited to the particular state of the patient, are among the most effectual means which we possess for preventing consumption in persons predisposed to it, more especially in early life. Chronic Bronchitis.—The morbid condi- tions of the mucous lining of the larynx, trachea, and bronchi are greatly influenced by climate, and the change from a cold and moist to a mild and dry air seldom fails to relieve, and occasionally removes them. The situations which have been mentioned as most favourable in phthisis are best suited also to bronchial diseases generally. Of the continental climates, those of Rome and Pisa are the most beneficial in cases attended with an irritable state of the affected parts without much secretion; and that of Nice in cases attended with le^s sensibility, a more copious expectoration, and a relaxed state of the system generally. Ma- deira, as far as our experience goes, has proved more beneficial in the former class of cases than in the latter. In England, Torquay and Under- cliff' afford the best climates in the first class of cases, and Clifton in the latter, in which Brighton also is a very favourable residence during the autumn. Asthma is often greatly relieved and occasion- ally ceases under the influence of a mild climate, more especially when complicated with disease of the bronchial membrane, as it almost always is when of some duration. In what has been termed humoral asthma, Nice is the best residence ; but Rome is preferable when this disease is accompa- nied with an irritated state of the digestive organs, a complication which is exceedingly common. Chronic Rheumatism.—Climate produces the most decidedly beneficial effects in this disease, and that often with surprising rapidity, even in cases of long standing, which have resisted the best-directed medical treatment. We would par- ticularize Rome and Nice as the best residences for invalids suffering from this complaint. The preference to be accorded to the one or the other place will depend upon the character of the pa- tient's constitution and the state of his digestive organs. When there exists an irritable state of these, we have already remarked that the climate of Nice will generally disagree, whatever may be the more prominent disease. [Signal benefit is often derived, during the summer, from the Warm Spring and Hot Spring baths of Virginia.] Gout is remarkably alleviated by a warm cli- mate. In the selection of a residence for the gouty invalid, we must be guided by the particular state of his constitution, and the effects of the different climates which have been already pointed out. Genoa is rather remarkable for the rare oc- currence of the disease among its inhabitants. But a warmer climate than any part of Italy would, in many cases, we have no doubt, prove still more effectual in removing gout We have already remarked the effects of the West-Indian climate in this disease. Scrofula. — Strumous affections, especially when seated in the skin and lymphatic glands, are frequently cured, and the general health is greatly improved, by a mild climate. In such cases Nice and Rome have appeared to us the most favourable residences ; but in giving a pre- ference to either, in this and all other complaints in which a residence in these places is useful, the practitioner must always keep in view the charac- teristic peculiarities of these climates formerly pointed out. There are cases of this disease in which the climate of the West Indies, as already remarked, would prove more effectual than any European climate; those, namely, of an indolent character with little disposition to febrile excite- ment. Dyspepsia. — Different forms of dyspepsia, hypochondriasis, and other nervous affections, in- timately connected with a disordered state of the digestive organs, all of which are aggravated by a cold and humid atmosphere, are much mitigated by a winter's residence in the south of Europe, if aided by proper regimen. Attention to the diet is particularly necessary in changing from a cold to a warm climate, and in no class of cases is this more requisite than in those of which we are now treating. (See Dyspepsia.) The dyspeptic invalid from the north will re- quire to be still more on his guard in the south of Europe than in his own country, particularly as regards the use of stimulants; but in nervous and hypochondriacal cases the state of the mind must always be taken into consideration in our selection of a climate and residence for the invalid. Unless we can produce an impression on the mind as well as the body, we shall make little progress in the cure of these affections. A change from one place to another will, generally speaking, be better than a long residence at any one; as much of the benefit obtained in such cases arises from a constant succession of new and agreeable impres- sions made upon the mind. A judicious and timely change of climate, combined with a consi- derable extent of travelling through a country and scenery which excite a lively interest, produces the best effects on the health of persons whose minds have been overstrained and exhausted by long-continued application to the same subjects, or whose general health has been destroyed by chronic dyspepsia, and the abuse of medicines, to which it too generally leads. A single season properly spent in the south, more especially in Italy, is often productive of the most salutary effects in restoring, the energy both of the mind and body; and if due attention is paid to regimen, especially as regards diet, the benefit derived will be both greater and more per- manent than can be obtained, perhaps, from any other mode of treatment The morbid states of the mucous membranes generally are greatly benefited by a mild climate. We have already remarked its beneficial effects in the diseased conditions of the bronchial membrane, and that of the stomach, in dyspeptic affections. In similar states of the intestinal membrane, ac- companied with chronic diarrhoea, a mild climate will contribute powerfully to restore the parts to a healthy state. Dysmenorrhcea, which is frequently dependent on irritation of the mucous membrane of the uterus, is often quite removed, and the healthy state of the whole uterine functions re- stored. 452 CLIMATE Irritable cutaneous diseases are also much alle- viated by a residence in a warm ciimate. It would be impossible, without extending this article to an undue length, to particularise all the disordered conditions of the system in which the change to a mild climate proves useful; but we must not omit to notice several distinct periods of life at which the beneficial effects of such a mea- sure have appeared to us most striking, when from any cause the health has become deranged. The first is during childhood. From what has been said, in the early part of this article, of the opera- tion of a mild climate on the various functions, it will be easily understood how beneficially this influence must be exerted at this early period of life, in favouring the growth and development of the system ; and accordingly we have had abun- dant opportunities of observing the excellent effects produced on the health of delicate children by a residence of one or two winters in Italy. When the health of children is naturally deli- cate, or when it has been rendered so by some of the diseases of childhood, such as measles, hoop- ing-cough, scarlet fever, &c, no measure with which we are acquainted will prove so effectual in restoring the health as a change to a dry and warm climate. Again, about the period of puberty, or a little before this time, a change to a southern climate for one or two winters is a measure which, if judi- ciously advised and carefully executed, will seldom fail to improve the general health of delicate per- sons, and favour the full development of the sys- tem which takes place at this period of life; and when there exists a disposition to tubercular dis- ease, it will tend materially to obviate it. We beg however, to observe, that we speak of the effects of climate in those cases, not so much as a single remedial measure, as a measure which, while it contributes powerfully of itself to improve the health, favours the operation of a proper regimen, and such other remedies as the circumstances of the particular case may require. The third period of human life at which we have remarked the powerful influence of a mild climate in ameliorating the health, occurs at a more advanced age. The two first occur while the body is yet in progress to maturity, the third when it has passed the zenith of its power. In the first instance, a mild climate enables a delicate frame to attain more certainly ite full maturity; in the latter it prevents it from sinking prema- turely into decrepitude, and enables it to prolong its existence until the period marked for its natu- ral decay. From about the age of fifty to that of sixty, though not unfrequently at a much earlier period, either when the system is naturally weak, or the causes of disease have been powerfully applied. the impaired condition of health now alluded to usually supervenes. This state is marked rather by anomalous disorder of various functions, indi- cative of a premature decay of the powers of life, than by any formal disease acknowledged in our systems of nosology. The activity of the mind and the bodily vigour have sunk many degrees, without any evident cause, and the individual, ooth in appearance and feeling, seems rapidly lapsing into premature old ago and its accompa- nying infirmities. This disordered state of the health has been termed the Climacteric Disease,- but, as we have already remarked, it occasionally occurs long before the period of life at which this change of the constitution is stated to occur natu- rally. (See Age.) The causes which lead to this condition of the health are various; as, for instance, an anxious and sedentary life, long-continued and close men- tal application, or irregular and intemperate habits of living ; and oftener still it is the consequence of the combined influence of several of these causes. From whatever cause it originates, a change for one or two years to a milder climate will prove of the greatest benefit in restoring the invalid to his wonted health. Before closing this brief survey of climate, and of the various diseases benefited by it, there remains one circumstance to be noticed, and it is one of some importance to the invalid : we allude to the proper period for his returning to this coun- try from the milder regions where he has been sojourning. Invalids finding a very sensible im- provement in the state of their health, are too apt to consider themselves well, and become impatient to return home on the least feeling of inconve- nience from the heat of the spring. Influenced by this or other causes, they frequently err by leaving a southern climate too early. A relapse of the disease, for the cure or relief of which they were sent abroad, is not unfrequently the conse- quence; and thus it often happens that by a little impatience, or imprudence, and occasionally from ignorance of the consequences, the advantages obtained by passing a whole winter in a mild climate are speedily destroyed. It should be the care of the medical adviser to warn his patient, before he leaves his own country, of the risk he runs by returning home too early. If his winter residence has been Italy, the invalid should avoid recrossing the Alps till the summer is fairly esta- blished in Switzerland. He may commence his journey northwards from his winter quarters in May, but should linger in the north of Italy, or among the Italian lakes, till he finds the heat inconvenient. This will seldom happen before the first or second week of June; and whatever may be his feelings in Italy, the period we have just mentioned will be sufficiently early to arrive in Switzerland. Independently of the risk of exposure to cold while crossing the Alps, which may, indeed, be avoided by proper clothing and arranging the day's journey so as to complete it before sun-set, the invalid will find a remarkable difference between the atmosphere of Switzerland and that of Italy. He will be particularly sensi- ble of the keenness of the evenings and nights in Switzerland. Indeed, the scenery of these two countries does not differ more remarkably to the eye than does their climate to the feelings. When the winter has been passed in Madeira, or any of the other Atlantic islands, and more particularly the West Indies, the invalid should be still more careful not to leave his quarters too early in the season. By a little care to avoid ex- posure to the sun, he may escape injury from the heat.; but it will be difficult for him to guard CLIMATE —COLD. 453 ■gainst the pernicious effects of our cold north- east wind as he enters the Channel, or arrives on our shores. A delicate invalid who has passed the winter in any southern climate, should endeavour to arrange his journey or voyage so as not to reach England before the middle or rather-the end of June; and his warm clothing, which he may have laid aside, should be resumed the moment his feelings tell him that he is entering a colder and more variable climate. [Invalids who have passed the winter in the West Indies, or in the southern part of the United States, should be especially careful not to return too early to their homes. The spring months are markedly those of great vicissitudes, and trying to the delicate. Dr. Jackson, of Boston, who sends his patients chiefly to Cuba, directs them to remain there until the last of April; then to go to Georgia or South Carolina, and to return to Bos- ton very slowly, so as not to reach New England until-the end of June; and the course is precau- tionary and wise. (Sir James Clark, op. cit. p. 306.) Should the invalid be unable to pursue this course, he ought to remain in his winter retreat until the end of May, if practicable.] It is of the greatest consequence to invalids to maintain an active state of the circulation in the surface and extremities, which cannot be done in this country without the assistance of warm clothing. The increased circulation in the ex- treme vessels is one of the effects of a warm climate, from which the invalid derives the greatest advantage; and it should be his especial care to preserve it while in progress to and after his arrival in a colder, as to the steady maintenance of this for a considerable length of time he must mainly look for the preservation of his new stock of health. In leaving his own country, therefore, in the early autumn, on his way to a warm climate, and in returning home in the succeeding spring, he should avoid exposure to great vicissitudes of tem- perature, and thus endeavour to secure the advan- tages, as it were, of several successive summers. James Clark. COLD.—It is designed under this head to treat of the morbid effects of excessive cold applied to the human body, and of the means of removing them; and also of the application of cold as a remedy in diseases. The term cold is relative, and, perhaps, strictly speaking, ought to be restricted to that sensation which is produced in the animal body by the ab- straction of caloric from it, in consequence of the application of any solid, fluid, or gas, of a lower temperature than itself. In common language, however, cold is spoken of as a positive agent, and by some men of science it has been supposed to have as distinct an existence as caloric, or the matter of heat The result of some experiments instituted to demonstrate that cold may be radiat- ed in the same way as caloric, appears to have confirmed this opinion in some minds; but the effects produced by those experiments are expli- cable on the supposition that caloric is radiated, and not an agent of an opposite character. The sensation of cold is not always produced by the same degree of temperature, for it depends very much on the state of the body previous to its application ; indeed, what may be considered a low temperature under some circumstances will cause the sensation of warmth, and a compara- tively high temperature will produce that of cold. If the right hand be immersed in water at the temperature of 80° of Fall., and the left in an equal quantity of water at 40°, the former will receive the sensation of heat, and the latter that of cold ; but if the two quantities of water be then mixed, and both hands dipped into the mix- ture at the same time, the feeling of cold will be produced in the right, and the feeling of warmth in the left; so that no fixed temperature can be called either hot or cold. The generation of ani- mal heat, or, in other words, the internal develop- ment of caloric, is accomplished by a process con- tinually going on in the body, more actively per- haps at some times than at others. The abstraction of caloric from the body within given bounds may be regarded as a salutary pro- cess ; on this circumstance the degree of vigour observable in the human frame, in temperate cli- mates, so much greater than in either what are called the torrid or frozen regions, may in no small measure depend ; the degree of abstraction being neither so great as to leave the system tor- pid, nor so slight as to render it oppressed. In- stinct and reason have led to attempts to regulate, | by various artificial means, this cooling effect of j the surrounding atmosphere in cold climates and seasons, as well as by contrivances for cooling the | air in hot regions, to protect the system against the effects of excessive heat; and it is a remark- l able fact, that a provision in nature seems in some | degree to be made to accomplish the same object in the animal kingdom ; for in very cold climates wool and hair grow abundantly long and thick on the. brutes, so as to protect them against cold, while in the hotter climates their skin is scarcely covered; and the same animal on being removed from a cold to a warm country, or from a warm to a cold one, is found to change the length of his coat. Thus dogs taken from England to India will often lose all their hair; and in our own cli- mate the horse is well known to have the length of the hair covering his skin regulated by the clothing in the stable. Perhaps the temperature of the atmosphere which is most congenial to the human body is a range between 55° and 70° of Fah.; but habit has much to do with this, as with almost every thing connected with the actions of the animal economy. An extreme degree of heat may be often endured without much inconvenience by those who have been long habituated to it ; and the same may be said of cold. But when the system has been making an effort, if the expres- sion may be used, to resist the bad effects of either a very low or high temperature, a great and sud- den change in the surrounding atmosphere is al- ways productive of inconvenience. This remark refers not to a change of climate only, but to the vicissitudes which may occur in the temperature of the atmosphere in the same climate. Persons who are strong and robust, however, feel less in- convenience from these sudden changes than those who are weakly ; hence the importance of regu- 454 COLD. lating the quantity of clothing according to the powers of the system, and especially according to the vigour with which the circulation of the blood is carried on. A very frequent exposure to changes of temperature will often enable the body to resist the ill effects of these changes, and affords another instance of the power of habit The fact just mentioned is illustrated by the good health often enjoyed by those persons who attend large furnaces, glass-blowers, smelters, &c. The won- derful power of the body to accommodate itself to the circumstances under which it is placed, is, in this particular, exemplified in a very striking way. Hence, undoubtedly have originated the various modes of attempting to harden the sys- tem, and thus to prepare it to resist the morbific agency of cold. It is undoubtedly true that such means will often give tone to weakly persons, and prepare them for the vicissitudes of climate ; but with such persons much care is requisite that the plan be not carried too hastily into effect. Indeed, it will be found that many cannot by any care be brought to bear it, and in such instances warm clothing must be mainly depended on as a defence from the sedative action of cold. This leads to the more special consideration of the morbid effects produced on the human body by the undue degree of the abstraction of heat from it. Caloric, or heat, as it is commonly termed, acts as a stimulant when applied to the animal body, its effects being local or general according to the extent and degree of its application : it increases, like most other stimulants, the action of the heart and blood-vessels; but (as is also the case gene- rally with stimulants) a secondary effect occurs, which consists in a collapse, (or in an action low- er than that which is natural,) after the excite- ment has subsided. Effects exactly the reverse of these take place from the abstraction of caloric, or, to use the common phrase, from the applica- tion of cold. Heat is therefore a stimulant, and cold a sedative, although the exact mode in which heat or cold acts on the body will probably never be determined. The well-known immediate effects of a con- siderable abstraction of heat are — the sensation which is called cold, pallor of the skin—from the absence of blood in the capillary vessels ; or a reddish blue colour especially of the hands, ears, nose, lips, from a delay of blood within the capil- laries, so that it becomes venous; — a shrunken .state of the skin, and a contraction of it around the small glands which are imbedded in it, and around the hairs, causing it to become rough, and to resemble the surface of a plucked goose; hence the technical term cutis anserina. The same state of the skin of the scalp often causes the hair to rise in some degree from the head, with a feeling of tightness; this is called hrrr'pilatio. The extremities of the body suffer first, as the fingers, toes, ears, nose, &c, /'. e. the parts farthest from the heart. The fingers and toes become sensibly smaller, so that rings which fitted before fall from the fingers, and shoes drop from the feet for which they were not previously too large. The action of the heart becomes diminished in force, and sometimes also in frequency—the latter being most commonly the result of exposure to a very intense degree of cold ; and not unfrequent- ly the pulsations, although weak, become more frequent than natural. These symptoms, which may be considered the moderate effects of cold, will vary greatly as to their degree in different persons exposed to the same low temperature: indeed, to some persons the abstraction of heat by the cold air of a frosty day affords a grateful feel- ing, and to such it may be really salutary: this will be referred to when speaking of the therapeu- tical effects of cold. In all persons, however, a very intense degree of cold will produce un- pleasant sedative effects ; and in those who have been previously debilitated, the powers of the sys- tem are depressed to an alarming, and even some- times to a fatal extent: indeed there are very few individuals who have such vigour as to be enabled to resist the consequences of exposure, without sufficient clothing, to the severity of the winter months in the frozen regions, or to the intense cold which is met with in passing over very high mountains. The vascular system is not alone affected by the agency of cold on the body, as is proved by the symptoms which occur in the more severe cases of exposure; the brain and nervous system generally being soon brought under its in- fluence. Perhaps it may be with propriety sup- posed that the nervous system primarily receives every impression from external agents; and that cold, therefore, first acts on this system, the vas- cular system being only secondarily affected: this question need not be here discussed. Numbness, or a want of the ordinary acuteness in the sense of touch, is a consequence of expo- sure to cold : this numbness is experienced by most persons in their fingers and toes on a very cold day, or after having been long immersed in cold water. It is worthy of remark, here, that in these individuals there appears to be something very peculiar as it respects the action of cold on their extremities ; the blood appears to cease to flow altogether into the vessels of the fingers and toes, which look exactly (as the common expres- sion implies) like those of a dead person ; and so torpid do they become under these circumstances, that a pin can scarcely be felt when placed be- tween the ends of two of the fingers, and the I motions of the hand are regulated, not by the | touch, as is usual, but entirely by the sight. This j singular idiosyncrasy has never received a satis- ! factory explanation : it does not appear to arise I from debility of the vascular system alone, for it is found in some who have no sign of such de- bility : probably it may depend, as all idiosyncra- sies appear to do, on an original peculiarity of structure: it is found to prevail in individuals of the same family. The very great diminution (almost suspension) of sensibility in such cases may arise in some measure from a want of the necessary supply of blood to the extremities of the nerves; as it is an undoubted fact that their sen- sibility is greatly regulated in its degree by the quantity of blood circulating through the capil- laries. It may also in part depend on the direct effect of the cold on the nerves themselves; but that this action on the nerves is not the only cause of the torpor is rendered probable, if not proved, by the fact, that if artificial warmth be applied so as to bring the fingers to their natural tempera- COLD. 455 ture, the sensibility will not return until the circu- lation is restored. The whole surface of the body becomes less sensible to the touch under the influence of a great degree of cold; and the sense of taste is sometimes blunted. But further, when a still greater effect is produced, the brain loses its energy, and an irresistible desire to sleep ensues. Here we may again observe that it is hardly pos- sible to determine whether this is the direct result of the action of the Cold as a sedative on the brain, or whether it depends on a want of the due supply of blood to that organ, on account of the diminished action of the heart. When this over- powering tendency to sleep has commenced, much danger is to be apprehended ; for it has generally been found, when indulged, to be the precursor of death. The interesting account given by Cap- tain Cook of the excursion of Dr. Solander and Sir Joseph Banks, with nine other individuals, over the hills of Terra del Fuego, affords a very strong illustration of this effect of cold. Dr. Solander, who had witnessed the torpor and death produced by severe cold while crossing over some of the mountainous districts of the north of Europe, thought it necessary to put his compan- ions on their guard, and requested them to resist determinately the strong tendency to sleep which he expected some of them would feel ; his words, quoted by Captain Cook, were, " Whoever sits down will sleep, and whoever sleeps will wake no more." The doctor was the first who began to experience the anticipated effect of the cold; and so irresistible was the inclination to sleep, even in him, that in spite of his judgment and fears he entreated his companions to allow him to lie down; they acted upon the knowledge he had afforded them for their own safety, and partly by entreaty and partly by force kept him for some time from indulging his destructive inclination ; but at last, becoming themselves almost exhaust- ed, they were obliged to leave him behind together with two black servants who had also become drowsy. Dr. Solander was, however, roused, although with the greatest difficulty, after having slept about five minutes only, and carried to a fire which some of the party had succeeded in kin- dling, and thus narrowly escaped death, although for a time he almost lost the power of his limbs. The two poor blacks perished. Many examples of this extreme effect of cold will be found on record in the writings of travel- lers and historians. [See Copland, art. Cold, Diet, of Practical Medicine; Dunglison's Elements of H:/giene, 2d edit.: Philad. 1814 ; Guerard, art. Froid, Did. de Med., xiii. 522 : Paris, 1836 ; and Veiter & Michaelis, art. Kalte, in Encyc. Wor- terb. der Medicinisch. Wisfenschaft. xix. 271: Ber- lin, 1839.] The same effect is produced, to a certain extent, in this country in very severe win- ters. The celebrated traveller Dr. Edward Daniel Clarke, the late eloquent Professor of Mineralogy in the University of Cambridge, was on one occa- sion nearly losing his life by cold. Having per- formed divine service at a church near Cambridge in the afternoon of a very severely cold snowy Sunday, in the year 1818 or 1819, he mounted his horse for the purpose of returning home. Soon finding himself becoming very cold and sleepy, and knowing well the danger of giving way to sleep, he put the horse into a fast trot, hoping by that means to arouse himself from the alarming torpor which was coming over him : this means was unavailing ; and then fearing that he should soon fall from his seat, he dismounted and deter- mining to use every effort to resist sleep, put the bridle under his arm and walked as rapidly as he could. This, however, did not long succeed : the bridle dropped from his arm, his legs began to falter, and he was just sinking down upon the snow, to rise, probably, no more, when a gentle- man who knew him came up to him in a gig, and rescued him from his perilous situation. This account was given to the writer of this article by Dr. Clarke himself the succeeding morning; he then felt languid and feverish, after having had a good deal of re-action during the night, but the effect soon passed off entirely. The action of cold is probably, as has been already remarked, greater on those persons who have naturally a weak circulation, or who have become weak from any debilitating cause ; and this last is the reason why those are very soon affected by it who have undergone much fatigue. A moist state of the skin from perspiration or damp clothing will also accelerate the effect of cold, by superadding to the direct effect of the cold air the further abstraction of caloric by evapora- tion. It is a curious but well-established fact, that when the mind is deeply engaged, the body is less affected by cold; and it is perhaps on this account that maniacs will often bear exposure to extreme cold without complaining. When the body is warm, and the circulation vigorous, provided there be no perspiration on the skin, the bad effects of exposure to cold are less likely to be experienced. The common practice, therefore, of persons cooling themselves gradually before they pass from a warm room into the open air has originated in error: the greatest protec- tion from the bad consequences of such a change is found in a vigorous circulation, a warm dry skin, and thick clothing. Long-continued immersion of the body in cold water seems to be productive of nearly the same symptoms as those which arise from exposure to a very cold atmosphere. It has been asserted, on the ground of recorded facts, that less danger is likely to ensue from immersion in sea-water than in fresh water; and it has been alleged that this minor degree of effect is referrible to the stimu- lating quality afforded to the sea-water by the salts which are dissolved by it. This solution of the facts is probably in part correct; but it must be remembered that the water of the sea is rarely so cold in winter as that of rivers, the immense mass of the ocean requiring a much longer period than that of a winter to cool it down to the lower degrees of temperature of the winter atmosphere : there must besides, by means of the tides, be a continual admixture of the warm water from the southern seas with the colder water of the north- ern. A doubt, however, cannot be entertained of the advantage which persons who are exposed to the misfortune of shipwreck during severe cold will derive from keeping themselves immersed ia the sea-water; and not only because the water is warmer than the atmosphere, but also because it 456 COLD. will prevent the effects of evaporation. Many interesting accounts of shipwrecks have b'.en pub- lished which show that this is not mere theory. The complete and speedy destruction of life from exposure to intense cold may result from the general sedative effect which has been already described; but when life is not totally lost, the extremities may lose their vitality, and mortifica- tion to a greater or less extent ensue. Limbs are frequently in this way mutilated in cold seasons in northern latitudes, and in very high situations ; when the surface of the nose and the ears suffers in this way, they are said to be frost-nipped or frost-bitten. But the injury sustained from exposure to cold is not always dependent on its direct sedative action, for it may produce disease, and even cause death, by that secondary effect which is denomi- nated re-action. This re-action after depression consists in the return of the action of the vascular system; if moderate, it may go little beyond the natural degree : the pulse becomes rather more frequent and full, and the heat of the surface greater than natural, and a glow is experienced over the whole body : this soon passes off, and leaves no evil consequences. But when the re- action is great, the vascular excitement is so in- creased beyond its due bounds as to constitute fever,- and perhaps there may be in reality no difference between this state of the body and fever from other causes. The symptoms are often the same, and sometimes last as long; but the fever- ish state in a day or two will give way, in many cases, on using very mild remedies, or even with- out any remedies at all; such cases are called ephemeral fever. Fever is not the only consequence to be feared from re-action after exposure to cold; local in- flammation may follow this general re-action, and any of the internal membranes or organs may become the seat of the inflammation; but the particular organ affected in each case may be de- termined by some local predisposition : thus one person will have catarrh, another cynanche ton- sillaris, a third pneumonia, as a consequence of exposure to cold. It appears from what has been said, that it is to the excess of the re-action that such effects, both local and general, are to be attributed ; and hence the importance of guarding against every circumstance which may have a tendency to sti- mulate the system immoderately after exposure to cold, and of employing measures calculated to subdue the action of the heart and blood-vessels when there is a threatening of sanguineous ex- citement. The danger of applying heat too rapidly is now generally known, as well as that of administering internally any strong stimulants. A person who has become seriously affected by cold should be placed in warm air about 65° or 70°, and should be well covered over with flannel to prevent the heat, as it becomes generated in the body, from passing off. Friction of the surface by means of the warm hands of two or three attendants, or with warm flannels, may be em- ployed : in extreme cases the body may be wrap- ped in hot blankets until re-action commences; large hot poultices or fomentations may be applied with advantage to the abdomen; the warm air, vapour, or water bath, about the temperature of 98°, may be employed in those instances where the vital spark appears almost exiinguished. The means already recommended must bo combined with the employment of internal stimulants, al- cohol, spices, ammonia, &c.: but it must be borne in mind that it is desirable to avoid the employ- ment of internal stimulants to any great extent: indeed, to avoid them altogether if possible, as, after re-action has commenced, they, by their action on the system, may cause the injurious consequences of excessive excitement. If asphyxia (or a suspension of the action of the heart and lungs) succeed to the application of cold, artificial respiration, and the other means recommended in the treatment of asphyxia, may be required. When the heat and action of the system begin to return, care is especially necessary lest the excite- ment rise to an immoderate degree. The same principle must be our guide in attempting to prevent injurious consequences after the local effects of cold. Chilblains, which are a common consequence of the local application of cold, may be prevented by warming the parts affected very gradually, and by cooling them, as soon as re- action takes place, to the extent of producing the sensation called the hot-ach. Large draughts of cold fluids, taken when the body is fatigued and perspiring, are often pro- ductive of serious or even fatal consequences: the effects are a faltering of the pulse, laborious breath- ing, dimness of sight, giddiness, and then general torpor and death. The proper mode of treating these cases has never been well pointed out; it appears, however, a rational practice to give, as soon as possible, some warm fluid, to apply hot fomentations or poultices to the epigastrium, and to resort to the means indicated by the principles already laid down. The abstraction of caloric from the body may and is frequently made to conduce to the recovery of persons labouring under disease. As a therapeutical agent, cold is employed to accomplish one of the three following purposes: —1st, to depress inordinate action of the vascular system; 2d, to relax the muscles; 3d, to give vigour to the body. The sedative effect produced by cold has been already sufficiently dwelt upon to show how it may be employed beneficially to subdue high vas- cular action. In inflammation, therefore, and in fevers, cold may very often be considered as one of our most valuable remedies. It may be sup- posed by some persons, that the beneficial effect resulting from the employment of cold in inflam- mation and fever, arises from the simple diminu- tion of the heat: indeed it is most probable that it was on occount of the augmented heat in those diseases that it was at first resorted to; but our present improved pathological views enable us to form a more correct judgment of the action of remedies; and there cannot now exist a doubt that the advantage arising from the use of cold in fever and inflammation is to be ascribed to its allaying vascular action. When inflammation is situated in the external parts of the trunk of the body, or in the extremi- ties, one of the means most commonly employed to subdue it is the application of an evaporating COLD. 457 lotion. The lotion may be used cold, and then the heat is in some degree abstracted directly by the cold fluid; but the principal advantage (unless the lotion is constantly applied) is derived from the evaporation of the fluid. It is not, therefore, absolutely necessary that the lotion should be colder than the body of the patient, as evaporation will take place more speedily when it is tepid ; and in some cases it is preferable to use it warm, on account of its being more agreeable to the feel- ings of the patient. Although there cannot be a doubt entertained of the advantage of employing cold applications in cases of common inflammation of the surface and of the extremities of the body, yet by many it is held to be problematical whether they are properly employed in cases of internal inflamma- tions, as of the membranes and organs included within the skull, the thorax, and the abdomen ; as by such means the blood may be so thrown upon the internal parts as to aggravate the in- flammation. As it respects the brain and its membranes, this reasoning, although at first sight plausible, is evidently fallacious. The object in cases of inflammation being to lessen the flow of blood to the part affected, any means which will control the action of the carotid arteries must be useful in inflammation within the head, as it is by those arteries that the greater part of the blood is conveyed thither. Cold applied to the scalp will be found to act as a sedative, not only upon the vessels of the integuments, but (by a sym- pathy which is well known to exist between the larger and the smaller vessels) upon the carotids also. It must be clear, therefore, even from theory, that cold applied to the integuments of the head will be of service in inflammatory dis- eases of the brain : but experience has long de- cided the point, and no practitioner omits this powerful remedy when he has to combat with such affections. The immediate effect produced by a sudden dash of cold water, or by a stream of the same poured upon the face and head, is found useful in many states of the brain. This mode of using the remedy is sometimes adopted with advantage in phrenitis, in hysteria, in syncope, and in cases where narcotic poisons have been taken in large quantities, especially opium. The advantage may be owing in some degree, as in inflammation, to the sedative effect of the cold upon the blood- vessels ; but this cannot account for the benefit produced in syncope, and the sudden impression made on the nerves by the cold must be also taken into the account. It seems to remain doubtful whether or not cold may with advantage, or even with safety, be ap- plied to the chest or abdomen when there exists inflammation of the membranes or viscera within those cavities. This practice has, however, of late been recommended by some physicians whose opinions ought to have weight, and especially so as the recommendation seems to be grounded on the result of experience : the limits of this article will not allow of a full examination of this inter- esting subject; the author, however, may be allowed to say, that in some cases of phthisis pulmonalis, where the pleura has become in- flamed, an evaporating lotion, applied over the Vol. I___58 2o part in pain, has often appeared to be of consider- able service. Cold applied to the body has become a very common remedy in fever, when the. system is in a state of very high excitement; and it is undoubt- edly a remedy of almost unequalled efficacy in such cases. It may be employed by means of cold fluids received into the stomach, or by means of water or air applied to the surface. From the time of Hippocrates the powerful effects of cold have been appreciated in controlling febrile action ; and it has from that period to the present time been occasionally lauded as an important thera- peutical agent: but it was not until of late years that its applicability in cases of fever became fully understood. We are more especially indebted to the late Dr. Currie of Liverpool for our knowledge of the value of this refrigerant, and of the mode of employing it, (on the Effects of Water, &c. in Fever, London, 1805 ;) although very valuable information may be found scattered through other medical works. It is not in all cases of fever that this remedy can be employed with advantage, or even with safety : it is only calculated to subdue excessive action when that action is accompanied by a temperature of the body above 98° : even among such cases there may be a few in which some other peculiarity may forbid its use,—for example, when the skin is moist At least, if it be employed under such circumstances, it will require the greatest caution, even although the temperature of the body be high, which, howe'-er, is very unusual when the skin perspires. In measles, cold is in no case to be applied to the skin, nor are cold fluids to be drunk. Neverthe- less, in scarlet fever cold is of the greatest service in moderating the action of the system. It is pro- bable, although not clearly proved, that where fever is accompanied by some visceral disease, this remedy may act injuriously, by determining a large quantity of blood to the internal parts of the body. The circumstances which, when combined, may justify the employment of cold as a sedative in common fever, are an increase of the animal heat above 98° of Fahrenheit, a uniform increase of temperature over the whole body, and a dry state of the skin over the whole surface. If there be a tendency to perspiration, it will show itself first in a damp state of the palms of the hands, or of the axilla?. Should a sense of chilliness be felt by the patient, that also will render the employment of cold of doubtful propriety. Several different modes of bringing the body under the influence of cold are resorted to by me- dical men. First, immersion of the body in a cold or tepid bath. Secondly, affusion of cold or tepid water over the body. Thirdly, sponging the body with a cold or tepid fluid. In some few cases, and in the very early stage of re-action, fever has been arrested in its progress by the cold bath or by cold affusion ; but where fever is fairly established, it can rarely be suddenly put a stop to by these or by any other means : we can then only mitigate the severity of the symp- toms, and thus give a better chance of the occur- 458 COLD. rence of a favourable crisis. But the practice of immersing the patient in a bath, or of throwing water over the body, has of late been very rarely adopted; and its disuse has not been without reason, for considerable inconvenience both to the patients and to the attendants is given, especially in private practice, by the employment of both these modes. But the principal objection to them arises from the impossibility of determining the precise extent to which we ought to carry the sedative effects of cold, while the body is immersed in the water, or while it is passing over it in the way of affusion. The patient may be kept too long or too short a time in the bath, or too little or too much water may be affused; so that the action of the system may be too much depressed, or not sufficiently overcome. These objections cannot be made to sponging the surface of the body with cold water : by this means the cooling process can be carried to the exact extent which is required ; the criterion for judging of the effect being the feelings of the patient — a slight chilli- ness will mark the time to desist. Two or three attendants should be employed at the same time, with large wet sponges, passing them over the different parts of the naked body in succession, until the chill comes over the patient, who is then to be placed in a dry bed and moderately co- vered. The temperature of the water when used with the sponges may not be a matter of much mo- ment, as it is by means of the evaporation that the heat is principally abstracted from the body : tepid water (from 70° to 90°) will in general be found most agreeable to the feelings of the pa- tient, and it will be equally, if not more speedily efficacious in reducing the morbid heat It seems also probable, for reasons already assigned, that re-action will not so quickly occur after tepid as after cold sponging. When the desired effect is produced by this mode of refrigeration, the pulse becomes softer and slower, the skin cool and per- spirable ; headach, if before existing, is relieved, and frequently delirium is suspended, and the general feelings of the patient are so improved that sleep will follow. The remedy will, how- ever, require repetition to derive from it its full advantage, and this should be as soon as re-action takes place to any extent; indeed the sponges may be used partially or generally many times in the day and night; but should the pulse rise very speedily, and the heat return very soon after it has been reduced by this remedy, other means must be combined with it, as bleeding, purging, &c: but in by far the majority of cases of fever, dependence may be placed on refrigeration alone to keep down inordinate action. Vinegar, spirit, ether, &c, are sometimes used to increase the evaporation, but these are seldom required. Cold air admitted into the patient's room, or a current of air passing over his body, will often tend to allay vascular excitement: hence poor pa- tients, in fever, who have been lying in their own confined apartments, are often speedily benefited by removal to an hospital through the open air. It is very questionable if any medicine admitted into the stomach is worthy, strictly speaking, to be called a refrigerant, at least to be called so on account of any quality which it possesses, except- ing its low degree of temperature, although many articles of the Materia Medica are reputed to have this effect; but on this point the reader is referred to the article Refrigerants. When hemorrhage occurs from increased action of the circulation, or is accompanied by such in- creased action, it may very frequently be restrain- ed by the sedative effect of cold. The local ap- plication of cold to the bleeding vessels, or cold so applied as to act upon the large vessels which supply those which are bleeding, will be often found of very great service; for example, in he- morrhage from the nose (epistaxis), cold water used to the face and head will often of itself stop the flow of blood; but in cases of bleeding from the internal organs, cold, made to act upon the system generally, will often be found of great use in helping to restrain the action of the heart A patient labouring under hemorrhage from the lungs (haemoptysis), may with great advantage be kept uncomfortably cold : of course when the he- morrhage is not active, but of the passive charac- ter, injury rather than benefit might result from the employment of this means. The depressing effect of cold upon the ener- gies of the animal body is remarkably exemplified in the debility which is felt in the muscles of a person who has been long exposed to a very low temperature ; indeed it is very probable that the sedative action of cold on the circulating system is to be ascribed to a diminution of the irritability of the muscular fibres of the heart and blood-ves- sels. When, therefore, an inordinate contraction of the muscles occurs, as in spasmodic diseases, the sedative quality of cold may cause them to relax when that remedy is applied to the body to a great extent The cold bath and cold affusion have for this purpose been frequently employed in tetanus ; the relaxation, however, which often occurs immediately after the application, is gene- rally of very short duration, and it ought to be remarked that the sudden shock experienced on the first impression of the cold water will often excite an exacerbation of the spasm, and that immediate death has ensued in a few instances. This mode of treating the disease is certainly, in general, far from being effectual; and it cannot be deemed altogether a safe one. The sedative effect of cold on the muscles has been said to show itself in alleviating the irregular actions in chorea, hysteria, and other convulsive diseases; in these cases the cold bath or shower bath has been recommended. As an instance of the effect of cold in producing muscular relaxation, it may be stated that surgeons are sometimes able to reduce with great ease a dislocated limb during the tem- porary debility, which is induced in the muscles after long immersion in a cold bath. There are, however, other remedies capable of producing re- laxation of the muscles, which must be consider- ed much more certain than cold. (See the article Antispasmodics.) The last therapeutical agency of cold which remains to be considered, is its invigorating qual- ity when employed in cases of debility, or, in other words, its tonic property. It has already been remarked that the direct effect of a moderately cold atmosphere is grateful and refreshing to the feelings of some persons; COLD —COLIC. 459 those who have naturally a very vigorous and too rapid a circulation, those who suffer from the pro- duction of too much animal heat, and those who are liable in warm weather to have an inordinate secretion from the skin, are generally benefited by the cold season of winter: by such persons, from their feelings, a cold frosty day will be called bracing and invigorating. To those individuals, however, who have a languid circulation, either naturally or as the effect of disease, cold weather is far from being either agreeable or beneficial. It has been found on inquiry that a severe winter is in this country, and especially in the metropolis, productive of more disease than a milder season; the old and the infirm being the chief sufferers, (Bateman, on the Diseases of London.) An especial reference must here be made to the beneficial effects of that moderate degree of the re-action in weakly persons which follows the ap- plication of cold to the surface. The glow which pervades the hotly, arising from the increase of the circulation, is often at the moment accompanied by a sensible increase of vigour and activity. The benefit appears to depend very much on the blood being thrown in greater quantity into the capil- lary vessels, and on a consequent increase of their action in preserving the well-being of every part of the system. Cold, therefore, in this respect, seems to act indirectly as one of the diffusible stimulants. (See the article Bathing.) Some kinds of diseases of the skin are bene- fited by cold or tepid bathing. When there is much inflammatory action of the cuticular ves- sels, it is desirable to avoid re-action, and this is best accomplished by the use of tepid water, (about 70°,) keeping the body a long time immersed, and afterwards preventing the skin from getting hot: in other cases, where an eruption seems to depend" on a torpor of the cuticular vessels, it is desirable to favour the occurrence of re-action. On the whole, the action of cold on the human body may be regarded as very important in a the- rapeutical point of view ; it requires, however, as all remedies do, much judicious management; but with such management it is every day made the means of alleviating sufferings and of prolonging life John Whiting. COLIC, (colica.) This term, derived from kwXov, colon, the name given to the large intes- tine, is in its medical application restricted to cases in which there is pain in the bowels, obsti- nate constipation, and generally vomiting, but without symptoms of pyrexia. The pain which accompanies enteritis and diarrhoea is denominat- ed tormina, or griping. Symptoms.—In cases of colic, although there be no tenderness at first, the attention of the patient is soon attracted by pain which is gene- rally felt near the umbilicus and in the lower part of the abdomen, though sometimes over the whole belly. In most cases it is relieved by pressure, so that the patient endeavours to get relief by lean- ing upon his folded arms, or upon the edge of a bed, table, or chair; sometimes by lying with his weight upon the abdomen. The pain, however, may be increased on pressure. Dr. Abercrombie states that an intestine which has become rapidly distended is painful on pressure, though by atten- tion the kind of pain can generally be distinguish- ed from the acute tenderness of peritonitis. The pain, although constant, comes on in paroxysms, accompanied by a sense of twisting or wringing, especially about the navel. The abdomen is sometimes retracted, or drawn inwards; and oc- casionally the partial spasmodic action of the ab- dominal muscles gives an idea of the formation of balls or knots in the belly. In other instances the abdomen feels tense, elastic, and sonorous on per- cussion, from accumulation of flatus, which, after passing through the intestines with a rumbling noise, is expelled, temporary relief generally fol- lowing its expulsion. These symptoms are usually from the first attended with vomiting, which is often so incessant, that whatever is taken into the stomach is sooner or later rejected; and in severe cases, from an inverted peristaltic action of the duodenum, the vomiting assumes a bilious character. A variety of this disease, called flatulent colic, is very common in dyspeptic persons, more par- ticularly in those who are ill nourished, or who are addicted to the use of spirits; and in children who are improperly fed, or whose bowels are dis- ordered. In this form there is little sickness, and seldom constipation, but painful retention of flatus in the bowels, the colic depending principally upon debility of the muscular fibres of the intestines. Another very painful affection of a similar nature, which is not unfrequently mistaken for the effects of gall-stones, appears to depend on flatulent dis- tention of the upper part of the intestinal canal— the duodenum and jejunum. In cases of this de- scription, the pain is felt chiefly in the right hypochondrium, often extending to the back ; and in consequence of the pressure on the ductus com- munis choledochus, where it perforates the duo- denum, the flow of bile is interrupted: hence these attacks are often accompanied or succeeded by symptoms of jaundice. In such cases, on the subsidence of the pain, there is usually a percep- tible movement of air in some part of the intes- tines, accompanied by a gurgling noise and dis- charge of flatus. The pain occasionally ceases entirely, but recurs at irregular intervals, vaiying from an hour to a day or two. This distention of the duodenum and jejunum is occasionally ob- served in dyspepsia, and in these cases bilious vomiting generally takes place. When inverted action takes place throughout the greater part of the alimentary canal, not only the contents of the stomach and small intestines are discharged by vomiting, but those also of the large intestines. The vomiting is then termed stercoraceous, and such cases are denominated ileus, or the ileac passion. The bowels, both in colic and ileus, are obsti- nately constipated ; so that ordinary doses of ape- rients do not act. At the commencement of the attack, the tongue is white, clammy, but soon acquires a thick coat- ing or fur. The pulse is often natural, sometimes rather slow ; but when the pain is excessive, or when the symptoms do not yield to the remedies adopted, it becomes quick, and the skin hot, indi- cating the threatening or supervention of inflamma- tion of the bowels: hence the occurrence of febrile symptoms in colic should never be overlooked. 460 COLIC. • Several divisions of colic, founded on the sup- i posed causes of the disease, have been proposed by systematic writers. Thus Cullen has enume- j rated no fewer than seven varieties. 1. Colica spasmodica, characterized by retraction of the umbilicus and spasm of the abdominal muscles. 2. Colica stercorea, arising from accumulation of the contents of the bowels. This form occurs in costive habits, and is speedily removed by active cathartics, which often expel an incredible quan- tity of fajces. 3. Colica meconialis is applied to the spasmodic pain of the bowels which infants suffer from retention of the meconium : it is evi- dently a modification of the last variety (sterco- rea). 4. Colica accidentalis implies the origin of the disease from acrid ingesta, and is frequently induced in individuals by particular articles of diet. 5. Colica callosa, in which there is a feeling of constriction ascribed to some fixed part of the in- testines. 6. The colica calculosa arises from the formation and retention of intestinal calculi. And, 7. Colica pictonum, produced by the poisonous effect of lead on the system, which will be after- wards particularly considered. All writers appear to agree in the opinion, that during the continuance of colic there is some cause which impedes or obstructs the passage of the alimentary contents. It is with reference to this obstructing cause that disputes among practi- cal writers have arisen. The solution, however, of these discrepancies will be found in the fact that the symptoms of colic originate in a variety of causes. Cullen was of opinion that spasm was the essential cause of colic, and founded his varie- ties of the disease on the supposition that the spasm is the result of the operation of different agents on the muscular fibres of the alimentary canal. Dr. Abercrombie, on the other hand, at- tributes the symptoms of colic to a certain loss of the muscular power in a portion of the intestine, in consequence of which it does not act in con- cert with the other parts, but becomes distended by the impulse from the parts above, which in the healthy state would have excited it to contraction. He therefore infers that in colic the distended part is the real seat of the disease, and that the con- tracted part is not contracted by spasm, but merely collapsed, because it is empty, its muscular action being unimpaired. It appears to us that the symptoms of colic may be referred to one of the following causes ; spasm, obstruction, over-distension, inverted action. Al- though Dr. Abercrombie calls in question the pos- sibility of spasm occurring in the muscular fibre of the intestines, he cannot be said to have proved this point; he has, however, made it clear that, in many instances where colic has been supposed to arise from spasmodic contraction of some part of the bowels, it ought to have been referred to another cause. It would require numerous f.iets to show that all muscular fibres are not occasion- ally liable to a state of spastic contraction ; and it cannot be fairly doubted that, when irritating mat- ters are passing through the bowels, such matters may cause an undue degree of contraction, so as to obstruct the passage of the contents of a portion of the tube which is above the point of contrac- tion. We can in no other way explain the occa- sional production of colic from acrid ingesta. We know, however, that obstruction giving rise to colic, often arises from organic diseases, such as stricture in some portion of the intestine ; various morbid growths in the intestinal canal diminishing its calibre; from hernial protrusion or internal hernias; intussusception or invagination ; twisting of the bowels, or a long band of organized lymph encircling them, forming a ligature. Colic also sometimes originates in adhesion between the ad- joining portions of intestine, between the intes- tines and other viscera, or between the intestines and the parietes of the abdomen. Moreover, ob- struction and a consequent attack of colic may arise from mechanical causes, such as collections of hardened faeces, calculous concretions formed in the intestines, large gall-stones, or hard sub- stances which have been swallowed and become impacted in some part of the alimentary canal. Many of these latter causes may act in conjunc- tion with spasm; indeed it is probable that spasm will, as Dr. Cullen supposes, often be induced by their presence, and that thus hard substances may be arrested in their progress downward by exciting a spasmodic action of the muscular fibres around them. It is also plain, when any of the causes of ob- struction just mentioned occur, that by the deten- sion of the gaseous fluid, or solid contents of the bowels above the point of obstruction, over-disten- tion of the intestines must ensue, the peristaltic action become inverted, or their muscular power altogether lost, as happens in an over-distended urinary bladder. It is an interesting subject of inquiry, whether, independently of any obstruction, the muscular power of any part of the intestines may sometimes become so paralyzed as to be in- capable of propelling its contents onwards; and whether from this cause over-distension can take place to such a degree as to cause colic. Dr. Aber- crombie, we have seen, has pronounced it to be his belief that the muscular action is entirely de- stroyed, the part which has been distended falling flat when it is emptied, and presenting a broad surface like an empty hag, without any tendency to contraction. He gives a case in which the pa- tient lived for eighteen hours, with a free external opening directly communicating with the distended intestine, but without any discharge taking place, though the part contained only air and fluid fasces, and in which, notwithstanding the intestine for a considerable space above the opening must have been entirely deprived of its muscular action: on examination after death the part presented only a uniform distension, without any remarkable change either in colour or texture. Dr. Abercrombie there- fore concludes that such want of power is the common, if not the constant cause of this disease. He gives also an interesting case, accompanied with painful local distension, in which, after resist- ing the most active purgatives, galvanism succeeded I in procuring copious evacuations. Cases of colic are, no doubt, daily observed, which appear to arise from this cause; and it is probable that this debility of the muscular fibre produces, in many cases, the painful gaseous distension which often succeeds to enteritis or violent diarrhoea. Is it not probable that colic from the effects of lead is pro- i duced in this manner ? Lead when applied ex- , ternally doe3 unquestionably destroy the tone of COLIC. 461 the muscular fihres of the limbs; and it would be a very remarkable circumstance, if the same agent caused paralysis in one part of the body and spasm in another. This species of colic, therefore, (colicapictonum,) may be adduced as a presumptive proof of the accuracy of Dr. Abercrombie's opinion, viz. that the symptoms of colic may require for their production nothing more than the loss of tone of the muscular fibres of some portion of the intestinal canal. In these cases the part of the intestinal tube which is affected will, from want of power, be incapable of propelling its contents onward ; and thus by continuing to receive with- out being able to transmit them, the portion of intestine becomes more and more distended, and at length the whole tract above the point of the accumulation assumes an inverted action. Dr. Abercrombie thinks that this loss of tone in the muscular fibre may be caused by rheumatism ; and as it is well known that colic often succeeds to exposure to cold, this theory is plausible. In colic arising .from spasm of some of the fibres of the muscular coat of the bowels, or by mechanical obstruction, the same distension and inverted action may take place; only in such cases they are the result of the obstruction, and not of the debility. It has been asserted by some writers, that an inverted action of the whole or of part of the alimentary canal, may be produced independ- ently of either debility, spasm, or obstruction : they adduce, in proof of this opinion, the speedy discharge by the mouth of fluids which have been thrown into the bowels by clyster. These last are called cases of simple ileus, and perhaps the evidence adduced to prove the existence of such a state is still open to controversy. Morbid Anatomy.—In the preceding account of the history of colic, it has been shown that the symptoms are dependent on a variety of causes, many of which are removable ; but those cases in which the colic or ileus is merely symptomatic of incontrollable organic disease in the alimentary canal, are beyond the possibility of removal. Dr. Abercrombie, to whom the profession is so largely indebted for the record of many valuable cases and pathological deductions, states that ileus may be fatal without inflammation, and gives two cases in which a large part of the small intestine was found in a state of great and uniform distension, without any appearance of inflammation. In other instances, besides distension, lividity or incipient gangrene has been found, but without any appre- ciable change of texture: in some cases the usual in- flammatory exudation was not observed ; in others there was vivid redness, and in more advanced cases gangrene, with and without exudation of false membrane. Hence the usual progress of the disease in the fatal cases is into inflammation and its consequences—the inflammation varying from a recent tinge of redness to extensive gan- grene ; and it should be kept in view that these changes may be going on in a latent form with every variety of symptoms. Indeed we meet with cases in which inflammatory exudation has gone on to a considerable extent before death, yet in which there was neither frequency of pulse nor tenderness of abdomen. Various kinds of mechanical obstruction have been found in fatal cases of ileus. The obstruc- 2o» tion is occasionally connected with disease of the intestine, with hernial protrusions, with adhesions between two contiguous portions of intestine; so that, as in a case recorded by Dr. Abercrombie, a turn of intestine insinuates itself between the two adherent portions. Various forms of internal hernia, twisting of a portion of the bowel upon itself, intus-susception or invagination and calcu- lous concretions (intestinal calculi), have also been discovered in fatal cases of ileus. The symptoms of colic have been traced to various organic changes of structure, which dimin- ish the caliber of the intestine. Under these are comprehended contraction or stricture of the bowel, which are situated less frequently in the small than in the large intestines; various morbid growths or tumours having their origin in the internal surface of the bowel, and which in their progress gradually diminish its diameter, till at length even liquids do not pass through the dis- eased or contracted portion. The following observations of Dr. Abercrombie are valuable from the practical inferences to which they give rise. " From a review of the whole subject, it appears that there is a remarkable va- riety in the morbid appearances in those cases which are usually included under the term ileus. We have seen simple distension without any change of structure, and we have seen even exten- sive inflammation and gangrene. We have seen in several instances the distension apparently tak- ing place at an early period, and gradually increas- ing through a protracted case, and then fatal, with little or no change in the texture of the part ; and in others, we have seen at a very early period, and with much less distension, extensive inflam- mation, and gangrene. It would therefore appear probable, that in the cases which assume the cha- racter of ileus, there is great diversity in the pri- mary state of the affected parts; that in some it consists of simple loss of muscular power, though it may pass into inflammation at an advanced period ; while in others it is at an early period connected with inflammation as a part of the primary disease. These cases seem to differ from enteritis in their symptoms chiefly by the absence of fever; and in the morbid appearances, by being fatal with simple gangrene, uncombined with the floc- culent or pseudo-membranous deposition, which is so prominent a character of enteritis. Now gangrene in the intestinal canal appears to be chiefly a disease of the muscular coat. A state resembling it is indeed observed occasionally in the mucous membrane; but the cases in which this occurs are accurately distinguished by their own peculiar symptoms, and they do not affect this part of the inquiry. When, in the cases now under consideration, therefore, we find gangrene uncombined with any other morbid appearance, we are perhaps warranted to conjecture that the muscular coat has been the principal seat of the inflammation. It seems to constitute a modifica- tion of disease of much practical importance, quite distinct from enteritis, and assuming simply the characters of ileu6; but a modification of ileus of the most formidable kind, and very rapidly fatal. We shall afterwards see reason to believe that inflammation may be seated in the peritoneal coat alone, producing a disease which may be fatal 462 COLIC. without any interruption of the action of the canal, or that it may affect the peritoneal and muscular coat at once, giving rise to the disease which we commonly call enteritis." (Pathologi- cal and Practical Researches on Diseases of the Stomach and Intestinal Canal, p. 140.) Diagnosis. — It is necessary to distinguish colic—1. from enteritis ; 2. from hernia ; 3. from obstinate vomiting, sympathetic of disease in some distant part The absence of fever, the pain being generally relieved by pressure, the aspect of the counte- nance, and the quiet soft pulse, will generally dis- tinguish colic from enteritis. It is however never to be lost sight of, that enteritis may not only exist, but may be proceeding to a fatal termination without frequency of the pulse or abdominal ten- derness. On the other hand, there may be abdo- minal tenderness from simple distension of a por- tion of the intestine, but without inflammation. The stage of the disease must also be taken into consideration; though in the primary there may be no inflammation, in the more advanced stage it may supervene, and thus prove fatal. When the symptoms of colic arise from a her- nia, the protrusion will generally lead to its detec- tion ; besides, there is no pain in the beginning at least, and when it does occur, it is more circum- scribed, and the tenderness does not extend over the abdomen until the hernia has existed some time, and has become strangulated. There are many diseases accompanied by sym- pathetic vomiting, which may, without sufficient care, be confounded with colic. The sympathetic vomiting may arise from renal or biliary calculi, but in these cases there are some local signs of the origin of the affection; in the former case, pain of the back, and along the groins to the testicle and thigh, and disorder of the urinary functions; and in the latter, a greater disturbance of the functions of the liver, together with pain chiefly felt in the situation of the gaH-ducts; besides, in neither of these diseases is there the same obsti- nate constipation of the bowels as in colic. [In the form of colic, generally termed 'bilious,' a vitiated condition of the bile has commonly been considered the cause; but in the mass of cases this is certainly a secondary result. The disease consists, essentially, in great impressibility of the nerves of the digestive tube, under which a neu- ropathic condition is induced : this extends to the liver, which, under the erethism, increases its se- cretion ; and, in like manner, an increase, and a morbid condition of the different intestinal secre- tions are occasioned. In this form of colic, prior to the appearance of the characteristic symptoms, the patient usually suffers under symptoms of dis- ordered stomach and intestines, bitter taste, yellow fur on the tongue, nausea, vomiting, &c. When the colic occurs, the pain is excessively severe, cutting and screwing. The thirst is great, and anxiety and restlessness are attendants. After a while, bilious vomiting supervenes, and the bowels, which had been previously confined, or with scanty discharges, are evacuated freely—the faces being largely mixed with bile. The symptoms then gradually abate, and terminate in entire re- storation to health. Very frequently, the disease is attended with fever, and the severest forms are apt to end in inflammation of the intestines and death. (Practice of Medicine, 2d edit. i. 163: Philad. 1844.)] Prognosis.—The prognosis in this disease must depend principally on the nature of the ex- citing cause. When it arises from acrid ingesta, such offensive matters will generally pass sponta- neously or by proper treatment, and thus the symptoms will cease. When, however, hernia, intus-susceptio, stricture, or organic disease, pro- duce an obstruction, of course the danger is in proportion to the hazard arising from the disease on which the colic depends; the symptoms of colic, in such instances, being entirely symptoma- tic of the primary affection. But, as we have seen, it is by no means an easy task, nay, often impossible, to distinguish the cases originating in such obstructions from those which are less dan- gerous; and the prognosis should therefore not be formed hastily in any case. It has been observed by Dr. Abercrombie, that ileus has been fatal while the contents of the bowels were of a natural appearance ; and when obstruction has existed, its entire removal has not been followed by corresponding relief of the symptoms. Treatment. — We have seen that colic may depend on causes which are capable of removal, as well as on incurable organic disease : and the symptoms in both classes of cases being nearly similar, it is impossible to ascertain whether or not the colic depend on causes capable of being removed: we must proceed on the supposition that the disease is still capable of being controlled. It is always, however, a necessary precaution to ascertain that the symptoms do not arise from hernial protrusion, as it has not unfrequently happened that hernia, which has been the cause of the symptoms, has been overlooked, and the life of the patient thus exposed to danger. When the practitioner is satisfied that there is no hernial protrusion, or that there is no evident external cause to account for the symptoms, it will be a safe practical rule in all cases of obstinate colic, more particularly if the pulse rise and there be tenderness of the belly, and the powers of the patient do not forbid it, to abstract blood, both with the view of anticipating inflammation, or subduing that which is to be apprehended, and as a powerful means of procuring the evacuation of the bowels ; the syncope, which generally follows bloodletting, especially if performed when the pa- ! tient is placed in the upright posture, being often ■ accompanied with this effect The bloodletting | may therefore be carried to this extent in all cases where the patient is vigorous, and even repeated I if the state of the pulse and other symptoms require it. In persons who are weak, and in elderly people, however, due consideration must be given as to the expediency of bloodletting. In such cases ! the topical abstraction of blood may be more ad- visable. It is a matter of nice practical inquiry, how far | the intestines should be stimulated by purgatives: | on this point Dr. Abercrombie truly observes that [ the adaptation of the remedies to the individual cases demands the utmost discretion : it is im- , possible to lay down any general rules. There COLIC — COLICA PICTONUM. 463 are some cases which yield at first to a powerful purgative, and there are others in which an active purgative is decidedly injurious. [Dunglison's Practice of Medicine, 2d edit i. 163: Philad. 1844.J With these sentiments our individual experience leads us to concur, as well as with the plan of administering, at short intervals, moderate doses of mild aperients. Sometimes large doses of calomel, eight, ten, or even twenty grains, will remain on the stomach, and in the course of a short time move the bowels ; in other instances very small doses of purgatives in combination, and frequently repeated, answer this purpose. Purgatives will often operate best when combined with sedatives, and this is explained by the effect of the sedative taking off resistance by allaying undue contraction in the muscular fibres of the intestines, while the purgative excites the general peristaltic action, and increases the secretions from the mucous membrane. Calomel combined with opium may be given with advantage every second hour for three or four times, and then a full dose of castor oil. If the oil be rejected by vomiting, it may be repeated with the addition of twenty or thirty drops of laudanum, and an ene- ma, containing castor oil and laudanum, be ad- ministered to assist the operation of the aperient. In some cases attended with most obstinate vo- miting, we have seen a drop of croton oil rubbed on the tongue, and repeated six, eight, or ten times, at intervals of half an hour, procure solu- tion of the bowels when every other purgative had been rejected as soon as it had reached the stomach. While we endeavour to act on the bowels by aperient medicines given by the mouth, and also in cases in which they are at once rejected, it is expedient to stimulate the colon by injections : these may consist of a combination of various purgatives in common use—infusion of senna, to which may be added neutral salts, cathartic ex- tract, croton oil, turpentine, &c. The forcible injection of a large quantity (five or six pints) of warm water, in which soap has been dissolved, has proved successful. The tobacco glyster has been administered when the ordinary remedies have failed. It should be exhibited with much caution. Dr. Abercrombie recommends that the enema should be made by infusing fifteen grains of tobacco in six ounces of boiling water for ten minutes. If no effect has been produced by this injection after the lapse of an hour, it may be repeated in the strength of one scruple to the same quantity of water ; and so on, until such effects are produced (slight giddiness, muscular relaxation, &c.) as show that its peculiar action on the system is taking place. It may then be repeated at intervals of one or two hours, if the case do not speedily yield. With these precau- tions he states that he has seldom seen any un- pleasant effect from the free use of this powerful remedy. He adds, if while the tobacco injection is used in this manner, mild purgatives, such as aloes and hyoscyamus, are repeated in full doses every hour or two, the treatment is perhaps that which is most generally adapted to the ordinary cases of ileus, with the assistance of one or two bleedings if the symptoms require it, and espe- ; cially if the patient be of a full habit Opiates | are very often useful in colic to allay pain. After a full bleeding, when there is tenderness, the ad- ministration of a full dose of opium, combined with an aperient, or thrown into the rectum by glyster, is often followed by relief of the pain, and evacuation of the bowels. Still, however, from the tendency of opium to diminish secretion and to suspend the peristaltic motion of the intestines, it should not be indiscriminately prescribed, but only when there are paroxysms of severe tormina. In these cases it should either be combined with a purgative, or, if given alone, it should be fol- lowed by some aperients. There are other measures which should be put in force: the warm bath; hot fomentations, to which laudanum may be added : large blisters or oil of turpentine may also be applied to the abdomen. When the means recommended have failed, some physicians have advised the administration of crude quicksilver in doses of one or two pounds. Sometimes the sudden dashing of cold water on the extremities, and the application of cold to the belly, have afforded relief by procuring evacuation of the bowels. These are severe measures, and are only to be adopted when the disease has resisted every other plan of treatment In cases in which the colic depends on in- curable organic disease, all measures are alike unsuccessful. The patient is generally, under such circumstances, speedily relieved of his suffer- ings by death ; though in some instances life is protracted for an uncertain period, during which the unhappy victim endures the greatest agony. The only resource left is palliation by narcotics, and other means calculated to soothe the sufferings. [In bilious colic, the great indications ot treat- ment are, first, to remove the spasmodic condition of the canal; secondly, to evacuate morbid secre- tions ; and thirdly, to prevent the occurrence of inflammation. In plethftic and active habits, bleeding may be prescribed, with frictions and stimulating cataplasms to the abdomen; glysters of soap and water with laudanum or spirit of tur- pentine may be thrown into the colon ; and should these remedies not be effective, full doses of opi- ates may be given by the mouth or rectum, until relief is obtained. Should there be danger of the supervention of inflammation, blood may be taken from the arm, or leeches may be applied to the abdomen, followed by the application of a warm cataplasm; with mild cathartics, as castor oil and laudanum, aided, if necessary, by emollient or ano- dyne enemata.] John Whiting.—A. Tweedie. COLICA PICTONUM. —This form of colic is generally traceable to the action of lead upon the body, and is so called from its occurrence as an epidemic at Poictou. It has also received the names Devonshire colic, painters' colic, plumbers' colic. It seems probable, from both fact and analogy, that this metal produces a specific dis- turbance of the animal economy, of which dis- turbance the symptoms of colic are only a mani- festation, so far as the alimentary canal partakes of the disorder. This agent, however, may pro- duce a local disease, the effect of its morbific agency showing iteelf more strongly in the part 464 COLICA PICTONUM. to which it is immediately applied. Persons who j are employed in lead manufactories, or in smelt- ing ores which contain lead, painters, who use much white lead, and plumbers are more parti- cularly the subjects of this disease; but it occa- sionally happens to patients who are employing some of the preparations of this metal for the cure of disease. Moreover this form of colic has oc- curred epidemically, and has been (as in the case at Poictou) supposed to arise from the employ- ment of the acetate of lead in clarifying wine, cider, and other liquors. (See the papers of Sir George Baker in the Transactions of the College of Physicians of London.) [The principal marks of lead cachexia are said to be—a peculiar bluish or bluish-grey tinge of the gums, which sometimes extends over the mucous membrane of the mouth generally, and which has been regarded by Dr. Burton (Watson's Lectures on the Principles and Practice of Physic, Amer. edit. p. 712 : Philad. 1844) as an infallible proof of the presence of lead oxide in the system ; the teeth at the same time become discoloured, and affected with caries : there is a sweetish, styptic, astringent taste in the mouth, with a peculiar fostor of the breath; sallowness of the skin, and dull yellow tinge of the conjunctiva, general ema- ciation, soft, small, compressible pulse, and in rare cases, a considerable reduction in the number of its beats. Of thpse symptoms, the discolor- ation of the gums and teeth is most frequent, and most characteristic, and it is considered to be owing to the deposition of a very minute film of sulphuret of lead on the mucous surface, and on the enamel of the teeth. It is important to attend to these premonitions, for of 1217 cases of lead colic observed by M. Tanquerel des Planches, (Traite des Maladies de Plomb.- Paris, 1839,) 1195 were previously affected with one or more of them; and in many instances, by attending to these premonitions, with temporary cessation from work, the threatened attack of lead colic was pre- vented.] This affection has more largely fallen under the observation of those physicians on the con- tinent residing where it prevails endemically. M. Ranque, Physician to the Hotel Dieu at Orleans, has given a clear account of it, as it occurred be- tween the years 1820 and 1826, among the per- sons who are employed in the white-lead manu- factories at Orleans; and from this physician's account the author is induced to lay before his readers the symptoms of the disease. At first the patient loses his appetite; he feels sick, with increased discharge of saliva from the mouth ; there is disturbance in the nervous system, and his nights are restless. He then vomits and dis- charges every thing he has swallowed, mixed with bile and morbid secretions; to this succeeds pain in the abdomen, which is at first not constant, but returns at intervals, these intervals being longest at the commencement of the disease. The pain is severe about the navel, the epigastrium, the hypochondrium, the loins, and above the crest of the ileum. As the disease advances, the pain is almost constant, but is usually most severe at night, and is not increased by pressure. The abdomen is generally flat, but sometimes feels* as if knotted, in other cases more or less distended. The disease is now attended with headach, pain of the limbs, especially of the inside of the thighs, knees, calves of the legs, ancles, and soles of the feet There is no fever ; the pulse, indeed, is often below 60 in a minute. Constipation of the bowels is an invariable symptom, although it does not always occur at the very commencement; the bowels are excessively obstinate, and when faces are discharged, they are dry and lumpy. The appearance of the urine is generally natural. The expression of the patient's countenance indicates distress, and there is great prostration. Symp- toms of inflammation of the peritoneum occur now and then at an advanced stage of the disease, indicated by tenderness of the abdomen, frequent hard pulse, and other febrile symptoms; and in some rare instances the cerebral functions are disturbed. The pain of the limbs is sometimes very speedily succeeded by paralysis, but it is more frequently after the severer symptoms have passed away that the extremities become so affected. [The disease, in the large mass of cases, ter- minates favourably. Of 500 cases, treated at La Charite, in Paris, only 5 had a fatal issue; and in 3569 collected cases, there were only 95 deaths, or about 1 in 30.] The appearances presented by dissection after death throw but little light on the nature of colica pictonum. Inflammation of any of the textures appears to be only accidental, and is probably the effect, when it occurs, of the strong purges which are often used, or of the distension of the bowels, which is usually, if not invariably discovered. It is particularly mentioned by those who have had opportunities of inspecting the bodies of persons who have died from the effects of lead, that the bowels appear remarkably pale, as if the quan- tity of the blood in the vessels was less than usual. As has just been remarked, the intestines are often greatly distended in some parts, but in others they are contracted. Whether this con- traction is the consequence of spasm, or (as Dr. Abercrombie would say) only the natural state of the tube when empty, it is not easy to deter- mine; and this uncertainty about the cause of the contraction renders it very doubtful whether the distension is the consequence of spasmodic ob- struction, or the effect of debility or paralysis; but as we know that the action of lead on other mus- cular fibres of the body is to destroy their tone, it is the most probable conjecture that those of the intestinal canal, when affected by this poison, cease to be able to propel their contents forward, and that in this way distension takes place. The foregoing history renders it clear that the action of lead upon the system is very general; and it also seems calculated to lead to the opinion that the symptoms arise from changes in the in- testines, analogous to those which are produced in other parts of the body. The primary impres- sion made by this metallic poison is probably upon the nervous system, which secondarily causes a change in the blood-vessels and the muscular fibres. Upon the muscular and vascular system it seems to act as a powerful sedative. It is pro- bable that it is on account of its sedative action on the capillary system that lead is found useful in some cases of hemorrhage and inliainination— COLICA PICTONUM. 465 may it not be from this same action upon the i capillaries that the muscles become paralysed t It is a well-known fact that without a due supply of blood to their texture, the muscles lose their tone. The shrunk wasted state, and the blanched ap- pearance of the muscles of persons who have died after having been paralytic from lead, seem to favour this opinion. In explanation of the primary action of lead upon the nervous system, it is difficult to form a reasonable conjecture. The acute pains which are felt at the commencement j of the disease in different parts of the body, forbid I the supposition that it acts as a sedative upon the nerves ; and the fact that the sentient nerves of the limbs, when the muscles are paralysed by lead, remain as sensitive as in health, favours the same conclusion. It may here with propriety be observed, that after the first severe symptoms of colica pictonum have been removed by free evacuations from the bowels, there remains usually great torpor of the alimentary canal, and that it is probable that this torpor is the result of a paralytic condition, more or less complete, of the muscular fibres which pro- duce the peristaltic action of the canal. Treatment. — The remarks on the nature of the disease tend to show that the treatment of colic arising from the poisonous effects of lead must be regulated by nearly the same indications as those which have been recommended for the treatment of colic from other causes. The object is, first, to procure a full discharge of the alvine contents, and afterwards to restore the bowels to their healthy condition. Purgatives, combined with sedatives, seem well calculated to fulfil the first intention; and no combination is better adapted than that of calomel and opium in the proportions already recommended. After a few doses, a large dose of castor oil, or a drop or two i of croton oil may be given ; enemata also will be found valuable auxiliaries; they should be admi- nistered about the time the purgatives may be expected to begin to act The warm bath, the tobacco enema, and the other measures suggested as useful occasionally in the cure of colic, may here also be employed ; and should there occur tenderness of the abdomen, or any of the signs of inflammation, bleeding from the arm or by leeches will be required. Emetics are employed largely on the continent At the Hospital La Charite, at Paris, a very complicated plan of cure is adopted, but which, when analyzed, seems to be analogous to that which has been recommended in this arti- cle, although strangely pursued : it consists of emetics, cathartics, enemata, diluents, and ano- dynes. (See M. Andral on Abdominal Diseases.) M. Ranque, in the memoir already alluded to, re- commends, on the ground of extensive evidence of its efficacy, the employment of strong counter- irritation to the abdomen and back by means of a plaster which contains cantharides and tartar emetic; and he also prescribes a liniment, made with some convenient vehicle, containing the ex- tract of belladonna, to be rubbed on every part where pain is lelt; he uses also belladonna in clysters; and the same sedative by the stomach, in the form of an ethereal tincture, (£i. of the powdered leaves to frjiii. of sulph. ether, of which twenty drops is the dose.) The only peculiarity Vox.. I. —59 in this method of cure is the counter-irritation, which may probably with advantage be added to the list of curative means. If the opinion be correct that lead acts as a powerful sedative upon the blood-vessels, no mea- sure can appear better calculated to meet this morbific effect than powerful irritants. It is a fact well established that the paralysis which re- sults from lead is most effectually treated by the use of blisters or other stimulating applications to the parts affected ; and may we not, on the same principle, (through the medium of the sympathy which is so obviously maintained between the surface and the parts contained within the abdo- men,) hope to rouse the activity of the circulation of the intestinal canal by strong irritants applied to the skin 1 When the first urgent symptoms are overcome, and the bowels have been made to act, great attention will be required to restore com- pletely the tone of the digestive powers. Besides those means which have been enumerated as ap- plicable during convalescence from common colic, astringents and stimulants seem particularly ser- viceable when a patient is recovering from colica pictonum. Alum in doses of Qi. with a few grains of ginger or capsicum, may be taken with decided advantage two or three times a-day, with an occa- sional aloetic purge. The desideratum in this stage of the ailment is to restore the tone of the weakened bowel; and this will be most probably obtained by the combined effects of external and internal stimulants and astringents, wholesome and nutritious food, and a free state of the alimen- tary canal. [Of late years, alum (gr. xv. to gij. every four or five hours) has been highly extolled, as well as sulphuric acid lemonade. M. Gendrin (Videcoq, art. Colique, in Diet, des Etudes Medicates, Paris, 1830) affirms, that he has cured more than 300 cases, by administering daily from a drachm to a drachm and a half of sulphuric acid, diluted in three or four pints of water. The cure was effected in three or four days. The experience of Gendrin has been corroborated by other observers ; but others, again, have not been so fortunate. (See the writer's Practice of Medicine, edit, cit i. 169.) It has been elsewhere shown (Art Artisans, Diseases of, p. 175,) that sulphuric acid is largely used in many lead works and laboratories, and with great success, as a prophylactic] The dry belly-ach of the West Indies is a dis- ease of nearly the same description as the colica pictonum, and so is the colic of Madrid, mention- ed by Dr. Pascal, (Mem. de Med. et Chirurg. Milit. 1826.) Dr. Musgrave, of Antigua, has, in the Medical Repository, 1825, given a very good account of the former of these two diseases which is so very common among the negroes of the West India islands. He attributes the complaint to a morbid condition of the liver; but, in the estimation of the writer of this article, without sufficient evidence. The condition of the alimen- tary canal, which has already been pointed out, and especially that portion of it, the duodenum, which receives the gall-ducts, seems sufficient to explain the disturbance of the biliary function which he describes. In the West Indies the dis- ease is attributed to the new rum which is drunk 466 COMA. by the slaves. Dr. Musgrave depends principally on mercury for the cure of this complaint, and carries it to salivation, assisted by bleeding and purgatives. It is evident that this gentleman is influenced in his plan of treatment by the patho- logical views he entertains of the disorder; and it is a question which no one is better qualified, by talent and opportunities, than himself to decide, whether the cure may not be accomplished by mercury more sparingly administered. John Whiting. [COLITIS. (See Dysentery.) COLON, DISEASES OF THE. (See Con- stipation and Enteritis.) COLON, TORPOR OF THE. This dis- ease is the source of anomalous symptoms, and, although generally the result of other morbid con- ditions, is worthy of a distinct mention. Many pathological phenomena, commonly referred to the heart and stomach, unquestionably acknow- ledge for their cause this affection. Diagnosis.—Torpor of the colon is thus de- fined by Dr. Copland, (Dictionary of Practical Medicine, Art. Colon, Torpor of the)—" General debility, with indigestion ; slow or irregular state of the bowels ; distension, borborygmi, or stridu- lous noises in the course of the colon ; frequently pain or uneasiness, sometimes with tumours in some part of this viscus." Causes. — Torpor of the intestine may be owing, at times, to defective action of the system generally, and of the colon in particular; but not I unfrequently it appears to be dependent upon j narrowness of the canal, which occasions a dila- tation of the intestine above the narrow portion, in which faeces or air may accumulate, and give rise to all the phenomena of ileus ; or by pressure interfere with the functions of neighbouring or- gans. Occasionally, hard tumours, painful on pressure, exist in the colon, especially in the ascending portion. The writer has attended many cases in which various evidences of indigestion were present, with irregularity in the alvine eva- cuations ; generally, constipation alternating with diarrhoea; great irregularity of the heart's action ; often intermission of the pulse; giddiness, appa- rently from modified circulation in the encepha- lon ; and undefinable uneasiness referable to the stomach and bowels, which is often relieved by a moderate dinner, so that the after part of the day may be passed in comparative comfort. Treatment.—This must vary with the cause, where it is appreciable. When the condition indicates general or local debility, the preparations of iron, as the subcarbonate or the citrate, or the sulphate of zinc, may be prescribed, with the Russian belt, and a diet easy of digestion. This course must be persevered in for weeks. Change of air should be recommended, and the bowels be kept open by enemata rather than by cathartics. Violent purgatives have always appeared to be positively injurious. Where narrowness of the canal exists, it must be treated as noticed under Constipation ; and when attacks of enteralgia supervene, they must be met as inculcated else- where. (See Colic) In almost all cases of torpor of the colon, the writer has found decided advantage from a gener- ous diet, restricted, however, in qtiantity, and from the use of a glass or two of dry wine, as sherry, at dinner. (Holland, Medical Notes and Reflections, Amer. edit. p. 108 : Philad. 1839; and the writer's Practice of Medicine, 2d edit. i. 155: Philad. 1844.) Robley Dunglison.] COMA, (from kZ, or >iu, to lie down,) a pro- pensity to sleep; in pathology, a suppression, more or less complete, of the powers of sensation, thought, and voluntary motion. This may occut in various degrees, from a state of slight temporary drowsiness and torpor to one of profound and permanent stupor with general paralysis both of feeling and motion. The mental powers alone may be affected, whilst sensation and voluntary motion remain unimpaired. There may be sus- pension only of some of the intellectual faculties, as occurs in somnambulism and several forms of lethargy ; or thought, sensation, and voluntary motion may be alike completely abolished, and life only sustained by a partial supply of nervous influence to the involuntary organs. These modi- fications of disease are easily accounted for by the natural divisions of the nervous system into parts having distinct functions. Coma is a symptom not characteristic of any one condition of the brain, but may exist in con- nexion with morbid actions very different and even opposite in their nature. Nosologists have on this account been greatly embarrassed how to dispose of comatose affections in their classifica- tions of disease, so as to bring them under one head. By attempting this they have introduced a degree of confusion calculated to lead to dan- gerous mistakes in praptice; for comatose affec- tions, decidedly connected with an inflammatory condition of the brain, have been erroneously ranged under the class neuroses or adynamia, to which classes some other of these affections, ori- ginating in debility, legitimately belong. Coma may either be a primary affection, or supervene, in the course of other diseases, as a symptom. In Cullen's system, comatose affections constitute the first order of the class neuroses, under the title Comata, which order is divided into two genera, apoplexy and paralysis. Those affections which are more especially comatose, such as apoplexy, cams, cataphora, catalepsy, ecstacy, and all the varieties of lethargy, are included under the first genus. Dr. Mason Good, in his Nosology, classes all the affections characterized by torpor, either mental or corporeal, under the genus carus, hav- ing six species—asphyxia, ecstasis, catalepsia, le- thargus, apoplexia, paralysis. The strong sym- j pathy which the different parts of the brain and i nervous system have with each other, establishes ! a close connexion between several of these forms of coma, and they not unfrequently pass into one j another. In the present article we intend to con- I fine ourselves to a brief description of the charac- teristic features of each of these affections; a more detailed history of some of them will be given under separate heads. By lethargy is meant a torpor both merit d and corporeal, with deep quiet sleep; it has a close affinity to natural sleep, differing chiefly in being I more prolonged, and depending on a morbid con- COMA. 467 dition of the brain. This is the slightest form of 1 coma, and has been termed also, by some writers, catapkora. i Catalepsy, or trance, is a total suspension of : sensibility and voluntary motion, mostly also of ! mental power : the pulse and breathing continue natural, the muscles are flexible, the body yield- ing to and retaining any given position. (See Catalepsy.) Ecstacy is a total suspension of sensibility and voluntary motion, mostly also of mental power; the pulse and breathing remain natural, the mus- cles are rigid, the body erect and inflexible. It is persons of a nervous temperament and ardent imagination, much given to reverie and deep ab- straction, who are most subject to this affection. The power of attention appears wholly concen- trated on one train of thought engaging only a few of the intellectual faculties, whilst the others remain in a state of complete torpor. The pa- tient seems to experience, for the time, a high de- gree of intellectual enjoyment This is the de- scription of ecstacy given by ancient writers, by some of whom it has also been termed catochus and catoche There is a complete abeyance of the mental faculties, of the external senses, of feeling, and voluntary motion, in the most perfect and aggra- vated forms of coma. The pulse is generally very slow, either full and soft, or small and hard ; sometimes intermittent, at others, however, rapid, feeble, and irregular. The breathing is slow, laboured, and stertorous, the stertor arising from the relaxation and paralysis of the muscles of the internal fauces. There is sometimes dropping of the lower jaw and distension of the cheeks at each expiration, with difficulty of deglutition. The pupils are dilated and insensible to the strong- est light: in some cases, however, they are either contracted or insensible, or one pupil is contract- ed and the other dilated. The surface of the body and the extremities are cold and clammy ; the patient lies supine, and there are several other distressing symptoms indicating the rapid approach of death. This is the form of coma that gene- rally attends diseases affecting the structure of the brain,—apoplexy, paralysis, meningitis, cerebritis, hydrocephalus, &c. It has been named by some nosologists cams. Others have described coma as a degree of torpor more profound than lethar- gy, but less than carus. Coma is sometimes at- tended with low muttering delirium, and has then been called coma vigil; and when resembling more a profound sleep, coma somnolentum. The attack of coma is sometimes sudden, with- out any premonitory symptoms, and it may as- sume at once its most aggravated character, ter- minating speedily in dissolution. In other cases the loss of sense and motion is less complete, and consciousness returns in a few minutes or hours. There may be a recurrence of the attack iu either regular or irregular paroxysms, as occurs in epilepsy. The invasion and progress of the complaint are, however, sometimes very slow. It commences by a tendency to drowsiness, which gradually increases until it reaches the state of complete coma. It frequently succeeds or alter- nates with convulsions and high delirium, and in such cases is to be considered a symptom of worse omen than delirium. The most frequent and obvious cause of coma is pressure on the brain. A state of perfect coma can be produced artificially by applying pressure to the brain of an animal, and the coma is reliev- ed the moment the pressure is taken off. The brain is exposed to pressure from a variety of causes. The principal of these are, congestion, inflammation, effusions of blood, pus, or serous fluid, organic tumours seated in the brain, in its membranes, or on the parietes of the skull, frac- tures of the skull, with depression, &c. Coma is perhaps too frequently attributed to serous effu- sion in the brain, which may exist in a consider- able degree without any coma, more especially when it takes place very slowly. Sudden attacks of temporary coma sometimes occur in conse- quence of the distended state of the stomach and bowels, compressing the large vessels in the neigh- bourhood of the heart, and causing an accumula- tion of blood in the head. Another very important and not uncommon cause of coma is a deficiency of nervous energy of the brain. There are various ways in which this may happen. It may take place suddenly, as the consequence of a violent shock or commotion given to the brain by a fall or a blow, causing some temporary derangement of the contents of the head, and suspending the operation of the nervous principle; this is termed concussion. The same effect may be produced without any physical cause, by violent impressions made on the nervous centres, and suddenly paralysing, as it were, the action of the nervous principle, as some- times happens after strong mental emotions, or the intense pain of severe operations. In such cases the patient sinks into a state of profound coma, from which there are instances of his never re- covering ; nature appearing, as is remarked by some writers, suddenly to relinquish the struggle. Intense cold acts on the brain and nervous sys- tem by producing a state of numbness and torpor which speedily passes into coma, and terminates in death. This loss of power in the functions of the brain, or in the nervous principle of the brain, may how- ever have occurred very gradually ; and the fact of this being a cause of coma is a highly important one, which, until lately, had been too much over- looked. The profession is much indebted to the late Dr. Good and to Dr. Marshall Hall for hav- ing directed their attention to this principle in pathology. After protracted attacks of inflamma- tory diseases, when the patient, although consider- ably weakened, is considered nearly convalescent, he sometimes falls into a state of coma, preceded occasionally by acute cerebral symptoms. Chil- dren are particularly subject to this variety of coma from exhaustion ; they lie in a state of insensibility, the pupils dilated, the eyes open and insensible, the face pale, the skin cold, and the pulse feeble ; they may continue for a day or two in this kind of stupor, and then recover. We ap- prehend, however, that these symptoms have often been mistaken for those of hydrocephalus, and that death has been hastened by the active treat- ment employed. There are in other cases symp- 469 COMA, toms of considerable nervous irritation, headach, delirium, great frequency and irregularity of pulse, general restlessness, which are sooner or later succeeded by fatal coma. This affection has been observed in persons who had long suffered from cate and perplexing situation great mental distress. Dr. Kellie and Dr. Aber- j patient may depend on his selecting the r.ght however, in these affections is sometimes involved in great obscurity ; and when the attark of coma is sudden, as the physician is required to act im- mediately, he may find himself placed in a deli- for the life of the crombie have attempted to give an explanation of these phenomena, which appears not unreason- | able ; they suppose that when the general volume ' of the blood is much diminished, that balance of j the circulation in the brain which seems neces- sary for the healthy condition of its functions is destroyed ; that the arteries of the brain become contracted in their caliber, in consequence of re- ceiving a less quantity of blood ; but that, as the whole quantity of blood in the head must always j continue nearly the same, a proportionate accu- mulation takes place in the veins and their si- nuses, producing venous congestion. The con- siderable venous congestion observed in the heads of animals which have been bled to death, whilst the other parts of the body are blanched, and drained of their blood, favours this explanation. Some of the old writers mention a form of apo- plexy analogous to this affection, to which they have given the name of apoplexia ex inunitione. A state of high mental excitement is in some cases followed by collapse and coma. This hap- pens in individuals endowed with a highly sensi- tive and irritable nervous system, possessing more imagination than judgment, and subject to alter- nations of great exhilaration and a proportionate depression of spirits. It is persons of this tem- perament who are generally exposed to attacks of lethargy, catalepsy, somnambulism, &c. The coma of hysteria belongs to the same class of cases. The use of certain medicinal and other sub- stances may be followed by coma, in consequence of their specific action on the brain and nervous system. This is the case with narcotics and spi- rituous liquors. The effects of spirituous liquors and of some stimulating narcotics, may partly be accounted for by their causing an increased flow of blood to the head, and a temporary congestion ; but, independent of this, they jiave a direct and specific action on the nervous energy, which they first highly stimulate and disturb, and next appear to prostrate and paralyse. This is what occurs in intoxication from alcoholic liquors and opium. There are other powerful narcotics, the effect of which seems to be that of at once paralysing and extinguishing the nervous energy without previous excitement, causing thus almost instantaneous death. This is the mode of operation of the upas, tobacco, belladonna, uma- tism. The old composition of sjap plaste. and muriate of ammonia, so useiul lor the knees of house-maids, is another example; but we muy find one still more laminar in the effect of new flannel worn next the skin, which unquestionably owes some of its salutary influence to its rube- facient property. To these instances of rube- facients we may add friction and electric sparks, both of which are essentially rubefacients: the latter often produce a papular eruption ; and the magnetic plates which have been recommended by some French physicians are asserted by Laen- nec to have a similar effect. These means, how- ever, will be noticed under their respective heads. Rubefacients, especially when extensively em- ployed, are general as well as local stimulants; and although their local effect is such as to coun- terbalance their general effect in cases of low febrile excitement, they cannot be admitted where a generally phlogistic diathesis prevails; whilst in intense inflammations they must give place to the stronger kinds of counter-irritants. Besides the examples of slight inflammation which we have adduced as fit cases for rubefacient applications, there are others of a mixed kind in wliich they are not less successful. Spasmodic affections, particularly those attack- ing the stomach and bowels, various pains and aches, such as tooth-ach, ear-ach, &c, which seem to partake of a nervous as well as of an inflam- matory character, are often more immediately re- lieved by hot flasks of fomentations, a mustard poultice or pepper plaster, than by any other rem- edy. These affections probably have more to do with congestion, or unequal distribution of the1 blood, than is generally supposed; and to this circumstance we are inclined to ascribe much of the efficacy of these applications: but it may also depend on the physiological law, that if the sen- sibility of a part is increased, that of the adjoin- ing parts is diminished. In great depression of the vital powers, as in typhus fever, asphyxia, &c, the general stimulus of sinapisms, stimulant fric- tions, and the like, is advantageous ; but we shall speak of this under the head of blistering counter- irritants. The most active kind of rubefacient counter- irritants are sinapisms or mustard poultices; and their action is so speedy and energetic, that they are the most eligible remedies where a sudden local irritant is required. They are usually com- posed of flour of mustard and bread-crumb in equal or in various proportions, moistened to the consistence of a poultice with hot vinegar. MM. Trousseau and Blanc, in the Archives de Mede- cine (Septembre, 1830,) have detailed some curi- ous experiments on the composition of sinapisms. They found that vinegar very much impaired the stimulant properties of the brown mustard com- monly used in France, which contains the husk as well as the flour of the seeds, and they there- fore recommended that sinapisms be made with water. The English mustard powder, however, which is the yellow farina separated entirely from the cortical part of the seed, is equally efficacious when mixed with vinegar and with water. Sina- pisms made from mustard recently ground act more promptly than those from mustard which has been for some time kept. M .'Vi. Trousseau and Blanc tried the admixture of aicohol with sinapisms, but found it interior to either vinegar or water. Dr. Paris recommends the mixture of oil of turpen- tine to quicken the operation of sinapisms; ite efficacy depending on its extracting the essential 528 COUNTER-IRRITATION. oil, in which the stimulant quality of the seeds resides. Sinapisms produce, in the course of a few minutes after application, a sense of heat, which increases to a smarting and burning pain of almost intolerable intensity. After a while this subsides, and is succeeded by a feeling of weight and fulness, with active throbbing of the arteries. In the course of twenty or thirty minutes the burn- ing pain again returns, and unless the patient be insensible from some cerebral affection, he can never bear the application of a sinapism beyond three quarters of an hour. The effects on the skin are remarkable. Applied for a few minutes, a sinapism does not produce a redness in propor- tion to the pain ; but a short time after its removal the part becomes of a scarlet colour. When left on for ten minutes and upwards, the skin becomes of a deep crimson or purple colour, which remains long after all sensation has ceased. Vesication is sometimes irregularly produced after forty or fifty minutes' application, but it is imperfect, and greatly disproportioned to the degree of inflammation. The intensity of the inflammation is such that there is considerable risk of gingrene supervening, if the sinapism remain applied for more than an hour. As long as sensation is preserved, the ex- cessive pain would be a security against its being too long applied ; but in cases of stupor and in- sensibility it should not, therefore, be permitted to remain beyond an hour. The pain excited by sinapisms may be allayed by cold applications, or, according to MM. Trousseau and Blanc, by cata- plasms of hyoscyamus, belladonna, and stramo- nium leaves, or by ointments containing extracts of these plants. Sinapisms are classed here be- cause their rubefacient is their most salutary pro- perty ; vesication and gangrene being their occa- sional or accidental rather than their desired effects. In the inflammation of organs which sometimes comes on in the progress of fever, in nervous and spasmodic disorders, and in inflammations dan- gerous rather from their seat than from their ex- tent, they are remedies of the greatest value. Vesicants.—The next degree of counter-irri- tation which we shall notice is that in which the excited capillaries throw out a serous fluid, which detaches the cuticle from the cutis, and raises it in blisters. The more powerful of those agrents which we have noticed as rubefacients, if kept applied for a sufficient length of time, produce this effect; but their vesicant is not always in proportion to their rubefacient property; and others which are more certainly and exactly vesi- cants, are more generally preferred. Several ve- getable juices produce an eruption of small blis- ters ; as that of some kinds of ranunculus, cle- matis, &c. But the Spanish blistering-fly, the cantharis, or meloe vesicatoria, is the remedy which best answers as a vesicant, and is the one almost solely employed. The active property, according to the researches of Rohiquet, appears to reside in a peculiar principle soluble in aether and in oil, to which is applied the name of can- tharidin. The form, therefore, in which it is most successfully applied is in a compound of the powdered tlies with hog's lard, or some such ole- aginous substance, and a due proportion of wax or resin to give it the cotisistence of soft plaster. This spread on leather, or any other convenient substance, and applied to the skin, soon produces a sense of heat and pricking in the part, attend- ed, if the application is large, with some excite- ment of the circulation and quickness of the pulse. If it be removed in two or three hours, its effect is merely rubefacient, and no blistering is produced ; but if it be allowed to remain for a space varying in different individuals from five to ten hours, the skin will be found raised in large blisters filled with a yellowish serum, which con- tinue to rise after the blister has been removed. In some cases they do not appear until after it has been dressed; and it is, therefore, unneces- sary to keep the plaster on until they are formed, or till, as it is commonly expressed, the blister rises. When the. blisters are fully risen, they are snipped with a pair of scissors, which allows the serum to escape ; and if it be intended that the part should heal, it is dressed with simple oint- ment spread on a linen rag. The serosity con- tinues to escape, and sometimes to raise fresh blis- ters, for some hours after; these must be treated as before, and the dressing renewed twice in twenty-four hours. The discharge of serum produced by blisters renders them evacuants as well as counteT-irri- tants ; and this property must be taken into ac- count in judging of their remedial powers. Until the vesication is complete, they have all those general stimulating effects which we have noticed as belonging to counter-irritants in general. But the serous effusion greatly modifies this, insomuch that after a blister is dressed, it is common to find the pulse weaker than before its application. The first excitement of a blister often communicates itself to the mental faculties ; its discharge com- monly causes a general depression, with a dispo- sition to sleep. These different effects are much more marked in some individuals than in others, and are necessarily modified by the existing dis- ease. But cantharides have properties of a pecu- liar kind, which not unfrequently exert an influ- ence on the general operation of blisters. When their active principle is absorbed into the system, it proves very irritating, and in a peculiar manner affects the urinary organs, causing strangury and even bloody urine. To obviate this, it is com- monly recommended to persons during the opera- tion of a blister to drink copiously of diluent mucilaginous liquids ; but we cannot refrain from expressing our conviction that this practice de- feats much of the good effect of the blister. In many inflammations, particularly in those of the thoracic cavity, a chief object of blisters is to re- strain the effusion of serum internally, or to pro- mote its absorption ; and this they do by extract- ing serum from the mass of blood in the adjoining vessels. But if liquids are thrown in such quan- tities into the_ stomach, they are rapidly absorbed into the circulating fluids, counterbalance the effect of blisters as local evacuants, and reduce them to simple counter-irritants. In such inflam- mations we are convinced by experience of the j advantages of abstinence from any bulk of liquid, j and would, therefore, look for other means to avoid the irritating effects of absorption from a [ blister. This may pretty effectually be obtained by interposing between the skin and the blistering | plaster a piece of thin gauze or muslin, moistened COUNTER-IRRITATION. 529 with oil, which being a menstruum of the blister- ing principle, transfers its effects to the skin, whilst the gauze or muslin prevents the particles of flv from adhering to the skin, after the separation of the cuticle has rendered it an actively absorbing surface. By taking care, also, not to allow the blister to remain on longer than is necessary, we may generally avoid these unpleasant conse- quences : six hours is generally sufficient; for whether the blister may have risen or not, if the skin at this time appear very red and inflamed, the vesication will almost uniformly take place after its removal. It has been asserted that by boiling the cantharides their peculiar effect on the kidneys is prevented, while their blistering power is unimpaired : of this we cannot speak from ex- perience. Before concluding our remarks on the reme- dial powers of blisters, we shall add a few cau- tions for their management The due contact of the blister with the skin is of importance; and this may be effected either by a bandage or by a few strips of adhesive plaster: but if too great a pressure be exercised, it will restrain the inflam- mation of the capillary vessels, and no vesication will ensue. It is not advisable to apply a blister to an excoriated surface, as the absorption of the acrid matter and its unpleasant consequences are very apt to ensue. When, from peculiar idiosyn- crasy, blisters produce great irritation, local or general, the addition of a little powdered opium or acetate of morphia to the plaster may give re- lief. An excess of inflammation, which occa- sionally ensues after the rising of a blister, some- times with erysipelatous or eczematous appear- ances around it, is best relieved by poultices, which are proper applications whenever it is de- sirable to moderate the irritation. When the blistered part shows a disposition to gangrene, which is not unfrequently the case with children, it must be treated on general principles, as by sti- mulating or other applications, solutions of chlo- ride of lime or soda, and brirk exhibited inter- nally. To avoid this consequence in children, it is advisable never to allow the blister to remain on more than six hours; and a poultice should be substituted if the inflammation be at all high. Simple blisters, or, as the French term them, vesicatoires volans, (in contradistinction to those which are kept discharging by an after applica- tion,) are remedies much and deservedly esteemed in the cure of inflammations. As rubefacients, or simple counter-irritants, they yield to sinapisms and other remedies which we shall presently no- tice; but their effect as local dcplctories gives them a superiority over most other counter-irri- tants. In common with the other remedies of this class, they are unfit for the first stages of ex- tensive acute inflammation ; but when the general excitement of the circulation, and the intensity of the orgasm, have been so lowered by blood- letting and other means, that the temporary irri- tation of the blister may be borne without risk, its action becomes highly salutary ; in the first in- j stance drawing off the irritability from the diseased part and then removing or exhausting it by an effusion of serum. This effusion proves the means of so deriving to the blistered part, that the mor- bid exhalations in other parte are re-absorbed and Vol. I____67 2o drained off; and hence blisters, more than rube- facients, are adapted to inflammations of serous membranes. Besides the caution required not to apply blisters at too early a stage, it is generally necessary to beware of placing them too near the seat of inflammation ; for their contiguity may greatly aggravate it, causing two inflammations, as it were, to run into one. This must be left to the discretion of the practitioner; but it may be suggested that in inflammations of the pleura,— in those superficially affecting the pulmonary sub- stance, as indicated by auscultation, — in those attacking the membranes of the brain or the larynx, it is better to place the blister on some part adjoining rather than immediately over the affected part; and to make up by extent of the surface blistered, for any diminution of effect from distance. In fact, in all acute inflammations large blisters are to be preferred to small ones ; for the irritation from the latter is nearly as great, with- out the same good effects. In chronic inflamma- tions the case may be somewhat different, as it is usually necessary to apply a succession of blisters; and the weakening effects of a large discharging surface might make small ones preferable. Of chronic inflammations, those affecting the serous and mucous membranes receive the most benefit from blisters. In pleuritic and peritoneal inflam- mations accompanied by effusions, their evacuant effects are likewise of decided utility; and with this view they should be of large size. But in inflammation of the parenchyma of the viscera, and in that of membranes without much liquid effusion, the more powerful counter-irritants are of greater efficacy. We have already noticed that rubefacients are sometimes valuable in continued fever, on account of the stimulus which they convey to the vital powers ; and we may extend this observation to blisters, which, judiciously administered, are often doubly useful, both by the general excitement which they afford, and by their local counter- irritation and evacuation relieving the several in- ternal organs, which almost constantly suffer in these fevers. But, equally as in the case of acute inflammations, during the stage of synocha or morbid excitement they must be excluded as inju- rious. It requires much nice discernment to decide on the time at which blisters may with advantage be used. Dr. Rush considered that there is a period in all fevers at which they would prove salutary ; but we shall not attempt here specifi- cally to define it. (See Fever.) By counter- irritants or revulsives of the most prompt and powerful kind, as boiling water, some signal cures have been effected in the worst forms of fever; the patient having been by them at once awaken- ed to consciousness from coma or extreme col- lapse. M. Marjolig cites his own case as an example of this treatment; and Dr. Macintosh records one which occurred in his practice eight or ten years ago : and we have heard of other instances of its success. As there is a great risk in the subsequent effects of the local injury, which generally tends to gangrene, this practice can only be resorted to in extreme cases. What has been said of rubefacients in spasmo- dic and convulsive disorders may be equally ap- plied to blisters, which are in fact the form genei- 530 COUNTER-IRRITATION. ally resorted to, although full blistering is probably inferior to sinapisms repeatedly applied for a short time. There is likewise a state of general irrita- bility of the system, accompanied with various and occasionally fugacious pains, but without hardness or fulness of the pulse, that is often greatly relieved by the application of a blister, which seems to localise the irritation, and thus relieve the system. An exception is commonly taken to the use of blisters in the case of inflammation of the kidneys and other parts of the urinary apparatus, on ac- count of the irritating effect of cantharides towards those organs through absorption; and although this may generally be prevented by attending to the precautions which we have before enumerated, it is acting safely to prefer some other counter- irritant This leads us to say a few words on other vesicating remedies. All those irritant agents which act in the most prompt and energetic manner, without destroying the cuticle, raise it at first into blisters filled with a serous fluid. Thus, boiling water, or its vapour, the concentrated alkalies, or metal heated in water, as recommended by Sir Anthony Carlisle, produce this effect. Intense heat, the strong acids and some metallic salts corrugating and destroying the cuticle, act more immediately as escharotics. But this mode of blistering is very unmanageable, as the inflammation accompanying it is of a diffuse and uncertain character, and often leads to severe sloughing. There is a method of applying the vapour of boiling water in a jet, by means of an eolipile, or vessel with a narrow orifice, which might be so regulated as to produce vesication without proceeding deeper; and the liquor am- moniae triturated with an equal weight of hogs' lard may be applied, so as to produce full blister- ing in fifteen or twenty minutes; but unless great speed is desirable, these agents, even thus modi- fied, are not eligible as mere vesicants. Pustular or Eiupyematous Counter-Ir- ritants.—We have hitherto referred to those de- grees of artificial external inflammation which ter- minate in resolution or serous effusion. There is, however, an important class of counter-irritants, affecting the cutaneous texture more deeply, and determining the secretion of pus. A blistered sur- face sometimes spontaneously takes on this degree of inflammation ; and the same effect is frequently brought on by, particular applications to it; but as these methods of counter-irritation are of a mixed kind, we shall presently return to them under the head of issues and setons, and here no- tice particularly those applications which bring on suppurative inflammation of the skin in the form of pustules. The sulphuric and nitric acids, their escharotic power being blunted by dilution with oil or lard, produce an inflammation, which soon assumes the form of pustules, small and distinct, or large and confluent, according to the proportion and strength of the acid used. But the substance most eminently calculated to excite the pustular inflammation is tartarized antimony. We owe the introduction of this medicine as a counter-irritant to the late Dr. Jenner, who employed it in the form of ointment, in the proportion of one part of the salt to five of spermaceti ointment It has since been extensively employed in practice, and is almost as generally used as a pustular irritant, as cantharides are to produce vesication. In our own hands we have found it so manageable as well as effectual a counter-irritant, that we consi- der it a remedy of equal importance with the blistering fly itself; but, as much of its efficacy depends on the method of its application, before describing its advantages we shall premise some precautions on this point. Tartar emetic exerts no corrosive or solvent power on the cuticle ; it therefore sometimes hap- pens that considerable difficulty is experienced in making the cutis feel its effects, and this obstacle is of course greater where the cuticle is naturally dense or thick. To obviate this we recommend the part to be previously excited, either by friction with warm flannel or a flesh-brush, or by some stimulating application of a penetrating quality, such as camphorated spirit or strong vinegar, or a mustard poultice applied for a few minutes. When the vascularity and sensibility of the skin have been thus exalted, the tartar emetic ointment is to be rubbed in, and it will then take a more equal as well as more certain effect: instead of having a few large and unmanageable sores pro- duced in two or three days, as is often the case in the usual method, a vivid erythema immediately succeeds, which in the course of a few hours breaks out into a thick crop of pustules, the size and course of which vary according to the strength of the ointment and the duration of its applica- tion. On these points it is not easy to lay down any absolute rule; for, as in the operation of blisters, much depends on the individual constitu- tion. We generally prefer an ointment of con- siderable strength, for instance, made with one part of tartar emetic and two of simple ointment If the fullest effect be desired, the friction, both preparatory and with the ointment, should each be persisted in for fifteen or twenty minutes. This generally leads to the speedy formation of confluent pustules, which go on to maturation. To diminish this effect it is best to shorten the period of friction with the ointment; and where we wish for the slightest degree of counter-irrita- tion, it is generally sufficient to smear the oint- ment on the part previously excited by dry fric- tion, or by some of the other applications before enumerated. Another mode of counter-irritation by tartar emetic is, the employment of a saturated aqueous solution : the elegance and convenience of this form render it peculiarly eligible where the oint- ment might be considered disgusting. It is ex- pedient to make the solution as warm as the skin can bear it, as the heat both enables the water to dissolve more of the salt, and quickens the effect on the skin. The part being previously excited as for the ointment, the solution is to be gently rubbed on it by means of a piece of flannel, and continued for a longer or shorter time, according to the degree of effect desired. The pustules thus excited are usually small and numerous, and un- less the application have been continued for some time or repeated, they dry up and heal speedily. As this application leaves no marks or seams, it is particularly suited to females, who generally renounce all medicaments which may leave a trace behind. Plasters sprinkled with tartar erne- COUNTER-IRRITATION. 531 tic in powder have been greatly recommended; i but we have found their operation very uncertain ; in some cases inefficient, and in others causing a frightfully ulcerated surface, which the removal ' of the plaster neeessarily exposes. After the ap- plication of the tartar emetic, whether in ointment or in solution, the part should be covered with a piece of rough flannel, which, if it be desired, may be made still further to promote the effect by a little ointment smeared on it. By this system of management tartar emetic may be made to produce any degree of counter-irritation, from a papular or erythematous blush to an extensively suppurating sore. Pustular or suppurating inflammation thus ex- cited is generally more permanent and profound in its counter-irritant influence than vesication. The formation of pus requires a greater develop- ment of vital action, a higher degree of local irri- tation than serous effusion, without proving more stimulant to the system. For this reason we consider the tartar emetic counter-irritant better adapted than blisters to remove deep-seated pa- renchymatous inflammation, even of the acute kind ; and although it must not supersede the free previous use of depletory measures, yet it may be employed with less hesitation than blisters, inasmuch as the absorption of the medicine into the system proves antiphlogistic instead of irri- tating. That such an absorption does take place is probable from the nausea which sometimes at- tends the use of the medicine; and we have known in a few instances violent vomiting ensue. In the method which we have recommended for its application, counter-irritation with tartar emetic may be brought to its greatest effect of copious suppuration in from ten to twenty hours, and a full pustular eruption may be brought out in five. This rapidity of effect places it on a par with blisters ; and the greater intensity of its in- flammation renders it a better counter-irritant. It is perhaps inferior to them in pleurisy, meningitis, and those inflammations in which the principal danger arises from serous effusion. In gastritis, likewise, its tendency to excite vomiting may render it objectionable. In most other acute in- flammations, if its proper application be attended to, we prefer it to blisters, and in none has it proved more beneficial than in those of the lungs and air-passages. In chronic inflammation the efficacy of tartar emetic counter-irritation is more generally acknow- ledged. We have found it far more beneficial than either blisters or setons in chronic bronchitis and pertussis; and if we can venture no further, we may unhesitatingly assert that we have seen it retard the progress of tubercular consumption. An eruption excited and renewed on the chest, sometimes on one side, sometimes on the other, seems in these cases to act as a safety-valve to the system, letting oft' any incipient disposition to in- flammation ; and thus, without much impairing the strength, enables the body to bear tonics, and a more generous diet than it would otherwise sup- port. It has been found of signal utility in dis- eases of the joints and of the bones, and is pre- ferred by some surgeons to moxa. Numerous cases of epilepsy, chorea, and other convulsive diseases, also cases of mania, paralysis, and neuralgia, have been recorded, in which tartar emetic counter-irritation on the nape of the neck, along the spine, or the course of a nerve, has pro- duced relief, and even a cure. But as in these disorders the scientific physician must sec patho- logical causes of very various nature, it would be irrational to assert that the remedy in question is universally applicable to them. As often as they arise from, or are aggravated by, some local inflam- mation, irritation, or congestion, we can at once perceive its utility ; but we can never be reason- I ably confident in our expectations of success when we remember how often there are immediate or- ganic causes for these diseases. In these and other complaints, nature not unfrequently throws out a hint in the form of a spontaneous eruption; and the physician may with great advantage be in- structed by it, and second her efforts by means of I this remedy. From the facility with which this counter-irritation may be excited and kept up for j any length of time by a slight fresh application, I it is well adapted to remove or prevent inflamma- tions of the eyes, ears, and fauces, which some- | times engraft themselves on the habit, and are very difficult to remove. A remarkable effect has been observed to ensue in a few cases from the use of tartar emetic oint- ; ment; namely, an irritation, sometimes very se- | vere, of the genital organs. We have never seen | this except in cases where the ointment had been used for several days in succession, which is rarely necessary according to the method which we have recommended for its use. When the inflammation excited by tartar eme- tic runs too high, it may, as in the case of blisters, be moderated by a warm bread poultice, which does not interfere with the progress of the pus- tules. Perpetual blisters, issues, and setons. — We have delayed to notice these counter-irritants, be- cause they are of a mixed nature, and occasionally partake of the qualities of all those which we have already described. The inflammation which they excite is of very various degrees of intensity, and the discharge which they occasion is sometimes purulent and sometimes serous. Blisters are kept open by removing the raised cuticle by scissors, and by applying, instead of the ordinary dressing, an ointment or cerate of an irritating quality. A small portion of cantharides is sometimes used for this purpose, but the bad effects of its absorption, which frequently ensues, raise a great objection to it. A cerate containing euphorbium and the unguentum resinosum has likewise been employed with the same view. But the ceratum sabinae is that most commonly resort- ed to; and, if duly managed, it is capable of main- taining a more equal degree of irritation and dis- charge than any other. It is, however, necessary to attend to the strength of the cerate applied; and if discharge be the principal object, it ought to be applied in a diluted form. Blisters kept open in this way, without profoundly affecting the skin, sometimes yield a copious secretion of pus, and then prove most salutary. With a continuance of the same application, however, this very com- monly becomes thinner and again serous; and in time the part is habituated to the irritation, dries up, and heals. To prevent this, it is necessary li 532 COUNTER-IRRITATION. remove the films of coagulable lymph which form upon it; to keep down vegetations by touching them with nitrate of silver or burnt alum; and occasionally to cleanse the surface by an emollient poultice, or by warm fomentations with flannel. By changing the stimulating ointment, the irrita- tion and discharge may be preserved much longer than when one only is employed. On the whole, however, this method of counter-irritation is trou- blesome and uncertain, and may well be super- seded by a succession of blisters, or by tartar emetic. By issues and setons irritation is applied more profoundly, being brought immediately into the subcutaneous tissue itself. The former are made by producing an opening in the skin, either by incision, by a blister, or the application of some escharotic substance, such as potassa fusa, nitrate of silver, muriate of antimony, &c, and intro- ducing some foreign body, as a pea or a glass bead, into it, which keeps up the irritation, and forms a constant ulcer. In producing the ulcer by means of caustics, it is necessary to limit the operation, and defend the adjacent parts by a piece of adhesive plaster, with an aperture in it of the required size of the ulcer. A bit of potassa fusa placed in this aperture in the course of four or five hours forms an eschar, surrounded by an areola of inflammation. This eschar being dressed with citrine, or other stimulating ointment, begins to detach itself and to secrete pus in the course of four or five days, and after that falls off, leaving an ulcer moie or less profound. Setons are made by passing a lancet-bladed needle, with a fasciculus of thread or silk attached to it, through a portion of the integuments (pinch- ed up between the finger and thumb), so that the threads are left in, with the ends hanging out at each orifice. To increase the irritation, the thread is anointed daily with the unguentum resinosum, and shifted or renewed to keep the wounds open or discharging. The necessity for the renewal is superseded by substituting a long strip of caout- chouc or of lead for the threads. The inflamma- tion at first excited by setons is sometimes so intense as to require the application of poultices to moderate it; and their dressing and manage- ment require many precautions which it is the province of surgery to teach. Issues and setons, when in full operation, ex- cite a phlegmonous inflammation, attended by a discharge of an abundant thick pus. This is most frequently the case with setons, and with issues formed by caustics; and these are, there- fore, the most powerful and profoundly acting of their kind. But like perpetual blisters, they are apt, with the same material of irritation, to be- come indolent and callous, and the secretion serous and less abundant. When energetic, these reme- dies are of great utility in chronic inflammations of various kinds. If any distinction can be made as to the kinds in which they are most service- able, it may be suggested that the circumscribed textural inflammation of viscera are peculiarly benefited by their use. When in a more moderate form, and secreting serum, they act rather as evacuants, and have been, not unaptly, compared to a new secreting gland in the system. They thus occasionally prove safeguards against apo- plexy, palsy, and other diseases of repletion; although implicit reliance ought not to be placed on such means. For the same reason they are proper adjuncts in the cure of long-continued cutaneous disorders, preventing any ill effects from the suppression of the natural counter-irritation. So, likewise, in all cases where setons or issues themselves have been for some time used, it is proper to be cautious in suppressing them, by doing it as gradually as possible, and carefully ensuring the free action of the bowels and other secretory organs. As a means of restraining the growth or diminishing the size of tumours and bronchoceles, setons have been found of some use; and the drains which they afford have likewise checked the increase of dropsical effusions. [There are other agents, which, according to their mode of application, are capable of inducing more than one of the effects already mentioned. When croton oil, for example, is rubbed in small quantity, and for a short time, on the surface, it induces inflammation of the skin, which gradu- ally disappears of itself. When the friction is longer continued, pustules are caused, which, when they are numerous, run together or are con- fluent; and, around the spot where the confluent eruption is seated, papulae appear over a wider extent, which are transformed into pustules, and are surrounded by a red base or areola. Com- monly, the eruption is perceptible in twelve hours after the first friction; but at times not until a later period. In the course of from three to six days, the eruption again disappears. The erup- tion is never so painful as that induced by the ointment of tartrate of antimony and potassa. Frictions with croton oil are adapted for all cases in which local counter-irritation is required. It is important, however, to bear in mind, that the oil may be absorbed, and act on the bowels, and may not, therefore, be adapted for intestinal dis- orders, in which counter-irritation is indicated. If the skin be thick, and insensible, it may be well to rub it previously with flannel, or to apply first a rubefacient, especially when it is desirable to produce the effect speedily. On the other hand, when the skin is excitable, the croton oil should be mixed with from one to four or five parts or more of olive oil, oil of turpentine, or soap lini- ment. (See the writer's General Therap. and Mat. Med. ii. 265: Philad. 1843.) The essential oil of mustard is occasionally used wherever a counter-irritant is needed. It is used either in the form of friction, or where a more powerful effect is needed, by dipping strips of linen, of the proper size, in the oil, and suffer- ing them to dry on the part. Burning pain im- mediately succeeds, and is often so insupportable, that the patient objects to wait until the linen is dry. (New Remedies, 4th edit p. 463 : Philad. 1843.) Ammonia has been employed to excite rube- faction and vesication. The pommade ammonia- cale of Gondrct has long been used in chronic affections of the brain, incipient cataract, amauro- sis, &c, being applied to the top of the head. (Gondret, Considerations sur TEmploi du Feu en Medecine, &c.: Paris, 1819 ; and Traite Theo- rique et Pratique de la Derivation, &c: Paris, 1839.) The formula for summer and for winter, COUNTER-IRRITATION. 539 recommended by M. Trousseau, (Journ. des Connais, Med. Chir. cited in Medico-Chirurg. Rev.: July, 1840) are as follows: for summer, three parts of lard, one of suet, and four of liquor ammoniac; for winter, equal parts of lard and liquor ammonix. More recently, a stronger and a weaker ammoniated lotion have been extolled ex- travagantly as counter-irritants by Dr. Granville. (Counter-Irritation, &c, Lond. 1838, or Amer. Med. Library edit.: Philad. 1838.) The milder of these is made as follows : Liq. ammon. fort. f.gi.: Spirit rosmarin. f.gvi.; Tinct. camphor. f.jii.M.; the stronger as follows: Liq. ammon. fort, fojx.; Sp. rosmarin. f.gss.; Tinct. camph. f.^ii. M. Raspail (L'Experience, 24 Juillet, 1840) has recommended the following lotion, the effects of which, he says, are often instantaneous in relieving intolerable headach : Liq. ammon. p. 100 ; Aqux destillut. p. 900; Sodii chlorid. pu- rif. p. 20 ; Camphor, p. 2 ; Essent. ros. q. s. The whole to be mixed cold. A piece of linen is to be steeped in this solution, and applied over the part of the head which is the seat of pain, care being taken that none of the fluid passes into the eyes. The stronger of Granville's lotions gives rise, in a few minutes, to vesication over the whole surface to which it is applied, almost as rapidly, indeed, as if boiling water were placed upon the part. The strength can be regulated so as to • produce either full vesication or simple rubefac- tion, by varying the quantity of the liquor ammo- nite. As a general rule, the application should be seldom continued longer than from one to six or eight minutes. But, in order to excite the higher degrees of counter-irritation, as vesication and cauterization, as much as ten or twelve minutes may be necessary. The mode of applying these liquid counter- irritants is first to impregnate with them a piece of cotton or linen, folded six or seven times; or a piece, of thick or coarse flannel ; and then lay either of these on the spot, pressing with the hand, at the same time, very steadily and firmly on the compress, over which there should be placed a thick towel doubled several times, so that not only the evaporation of the lotion may be im- peded, but the hand employed in pressing the compress on the part, may not suffer from direct pr indirect contact with the liquid. Care must be taken that the ammonia does not reach the eyes or nose. (Granville, op. cit. Amer edit. p. 39.) There can be no doubt that the ammoniated counter-irritants are valuable agents in all dis- eases that are benefited by a sudden and powerful revulsion, and especially in different forms of neu- ralgia. One great objection to them is, that they are apt to induce sloughing and sores difficult to heal. Care may prevent these ; but at times they occur in spite of every precaution. (New Reme- dies, p. 197.)] Cauterizing Counter-irritants.— By this term we designate all those operations in which heat, in such degree as to cause disorganization of the part, is applied as a counter-irritant The common effect of all these is the formation of an eschar, or dead slough, surrounded by a more or less intense inflammation, which causes the sepa- ration of the dead part and the production of an ulcerous cavity in its place. The local inflamma- tion, thus excited, may be very intense, and the suppurative discharge very perfect; and this kind of counter-irritation is proportionately energetic ir. ite effects on the disease, in the same manner as others. But there seems to be another peculiar result from the application of vehement heat: namely, a strong impression, or shock, on the nervous system, which in certain diseases is not without its salutary influence. Heat, with a view to cauterization, is applied by heated metallic instruments, burning substan- ces, boiling water or its vapour. Instruments of iron or copper, heated to different degrees of in- candescence, are sometimes used to produce local irritation and sores. This operation, which is called the actual cautery, produces, more than any other method, that shock to the nervous sys- tem to which we have just alluded. It has been found useful in checking violent convulsive dis- eases, such as epilepsy, hysteria, and local spasms. It is difficult to judge whether its efficacy depends on the pain, or on some other change wrought in the nervous system ; the effect is certainly some times produced before such a degree of local in flammation has been excited as could act by vas- cular counter-irritation. A red-hot iron is sometimes used to form issues; and for this purpose it is applied with considerable pressure to the part for eight or ten seconds, and repeated if it is wished to make the ulcer deep. A portion of skin and of the cellular texture underneath is thus killed, and forms an eschar, which in the course of six or eight days is sloughed off, and the ulcer produced may be treated as an issue. The painful and formidable nature of this operation excludes it from general adoption; and, with the exception of the cases just alluded to, we do not know that it can claim any superiority over that with caustic, which is attended with little pain. The good effects of the actual cautery are, perhaps, obtained with least attendant inconvenience when the metal is heated to a white heat. Thus applied, it immediately destroys the vitality and sensibility of the part; and if the surrounding skin is protected by cover- ings of wetted paper or other suitabte substance, in the way which has been recommended by Dr. A. T. Thomson, the suffering of the patient is much diminished, and the advantages of the remedy are with more certainty procured. The actual cautery is more frequently resorted to in surgery for the destruction of malignant produc- tions and morbific poisons. There is a method of cauterization, called by surgeons transcurrent, which partakes more than the preceding of the nature of a counter-irritant. It consists in lightly passing an iron, heated to a cherry red, on the surface of the skin in parallel lines, at such a distance from each other that an intervening space may be left free from inflamma- tion. In this way long narrow eschars are forrn- ed, which in the course of eight or ten days are enlarged; whilst the whole surface becomes high- ly inflamed, and is not relieved from the painful and phlogosed state of a common burn until a copious suppuration ensues, which often lasts for a fortnight or more. The fever and irritation which this process occasions forbid its employ- 534 COUNTER-IRRITATION. ment in any but very chronic and indolent cases. It has proved very successful in removing chronic enlargements of the joints, and the remains of rheumatic affections. Cauterization by substances in the state of combustion has of late years been practised to a considerable extent in the form of what is termed moxa. This method is said to have been adopted from Japan, where moxas are made of a down obtained from the leaves and tops of a species of artemisia, made into a cone, which when lighted burns spontaneously. The pith of the stalk of the sun-flower and of other helianthi likewise possess this property, which is owing to a small quantity of nitre in their composition. The ma- terial generally employed in Europe for moxas is cotton, rendered downy by carding, and made into a roll an inch long, and from half an inch to two inches in diameter. This is held by a forceps or wire, with one end in close contact with the skin, whilst the other is set on tire; the adjoining parts being protected by wet pasteboard or linen. The combustion is supported either by blowing or fan- ning, or by a slight impregnation of nitre pre- viously given to the cotton. The sensation pro- duced by the burning of a moxa is first that of warmth, rather agreeable than otherwise; this soon increases, as the fire approaches the surface, becomes itching, then more and more painful, and attains its acme of intensely sharp scalding pain when the combustion reaches the skin, which smokes and becomes crisp under it. The neigh- bouring skin is vividly inflamed, puckered, and sometimes slightly blistered. The eschar thus formed is deep, and requires a fortnight or upwards before it is separated. The ulcer formed discharges pus abundantly, and by the aid of a pea may be converted into an issue. The gradual manner in which heat is commu- nicated to the part in the burning of a moxa causes it to penetrate more deeply than any other form of actual cautery. Hence as a remedial agent it is well adapted to make an impression on deep-seated inflammation; and in diseases of the spine and its contents, in scrofulous and rheuma- tic swellings of the joints, in chronic diseases of the liver, kidneys, and other internal organs, in paralysis and neuralgia, it sometimes proves more effectual than any other remedy. It is often necessary, however, to employ several moxas in succession ; and if the disease be of some extent, several simultaneously, before the good effects become apparent. Moxas may be applied with greatest advantage as near as possible to the dis- eased part; but if their effect is intended to be deep, it would not be proper to apply them on parts where cartilage, tendon, or bone are close under the surface. Moxas are sometimes applied with a view to counter-irritate without producing an eschar. The moxas in this case are made of sun-flower pith, or of light cotton impregnated with nitre. The combustion is effected without blowing, and is not suffered to reach the skin. Under this form, fre- quently applied, they have been found useful in promoting the absorption of indolent effusions in joints and cold tumours. It is probable that much of their effect in these cases depends on the stimulus which they impart to the organic sensi- bility of the diseased tissues which cannot be included in their counter-irritation. [Various forms of moxa have been proposed. Mr. Leney (London Medical Gazette, July 15, 1842) soaks a piece of lint in a strong solution of nitrate of potassa, dries it, and cuts off pieces of the size of the thumb-nail, which he fastens, with thin adhesive plaster, over the seat of pain; sets fire to the opposite extremity, and then applies the blow-pipe. The pain during the process is very severe; but the Irish, he affirms, prefer it greatly to the application of a blister. Professor Griife (La Lancette Frangaise, Jan. 26, 1839) employs moxas made of wafers, dipped in a mix- ture of three parts of oil of turpentine and one part of sulphuric ether. Before applying this inflammable matter to the skin, it is necessary to remove carefully the superfluous liquid. These moxas are said to ignite readily, burn promptly and uniformly, and do not crepitate. Of late, a plan for exciting vesication on the surface has been adopted, which must be regarded as a kind of moxa. It produces rapid vesication, but is said to be complicated, and attended with intense pain, (Granville, op. cit. Amer. edit. p. 21 and p. 42.) A piece of linen or paper, cut of the requisite size, is immersed in spirits of wine, or brandy. It is then laid on the part to be blistered; care being taken that the moisture from the paper or linen does not wet the surrounding surface. The flame of a lighted taper is applied quickly over the surface, so as to produce a general igni- tion, which is exceedingly rapid. At the conclu- sion of this operation, the cuticle is found detached from the true skin beneath. In cases of convul- sions, the region of the spine has been treated in this manner, and with good effect (C. J. Ed- wards, Provincial Med. and Surg. Journ. Jan. 1842. See, also, the writer's New Remedies, edit. cit. p. 441.)] A cauterizing effect may be produced by boiling water, or better by its vapour. The best method of effecting this is by an eolipile, or vessel with a narrow tubular mouth, and kept boiling by means of a lamp. The jet of vapour issuing in full force from this is directed against the part, which is covered with thick pasteboard or linen, with an aperture of the form and size of the part intended to be cauterized. The pain caused by this opera- tion is very severe, and the slough formed very deep. It most resembles moxa in its effects; but the wound produced by it is less manageable, and more apt to involve the surrounding parts. C. J. B. Williams. CRISIS, Critical Days. (See Disease.) CROUP.—(Synonyms—Cynanche trachealis, C. laryngea, C. stridula, Angina polyposa, Suf- focatio stridula, Morbus strangulatorius, &c.) We prefer croup to the other appellations, inas- much as it does not convey an erroneous notion of the nature of the disease which it designates: that disease is not a mere cynanche, or quinsy. It will be shown that inflammation, which is the j characteristic of the order of diseases to which j croup belongs, is not confined to the throat, but I generally extends through the ramifications of the j bronchi; therefore, C. trachealis and C. stridula I ought no longer to be retained as nosological CRO terms. The terms suffocatio stridula and morbus strangulatorius are indefinite, and would equally apply to the various affections in which those symptoms of croup—the inspiratio strepens, vox rauca, and tussis clangosa—are engrafted on other diseases, and which will be treated of under their respective titles. This disease was honoured with the attention of the greatest man of the present age—if he can be called great who had no just sense of moral grandeur. In consequence of the general order which Napoleon issued from the head-quarters of Finkenstein,* many essays on croup were written by foreign physicians of ability, in which nothing is omitted in illustration of that disorder which industry could collect or method could arrange. Occasional Causes.—In the early part of his professional life, the writer of this article lived on the coast of the Firth of Forth, where croup may be considered an endemic disease, and where every facility was afforded for cultivating an acquaint- ance with it. During the last twenty-two years, while practising medicine in Dublin, his opportu- nities of witnessing croup have not been unfa- vourable, especially when attending a dispensary. While discharging that duty, he had frequent occasion to observe the disease among the ragged and half-starved children of the poor who live near the canals which surround the city ; or in Ringsend, near the estuary of the river Liffey ; or in Sandy mount, lying between Dublin and its bay: indeed the disease is prevalent, in the latter end of winter and in spring, along the whole of the eastern and northern coasts of Ireland. With respect to its prevalence along the rest of the sea- coast, no inquiries were made; his inquiries, however, sufficiently confirm the received opinion relative to the principal occasional cause of croup, viz. that in Ireland, as in Scotland, it is chiefly produced in the neighbourhood of large bodies of water, running or stagnant, fresh or salt. History. — The disease may occur at any period from the second'or third month after birth to puberty. The younger children are when weaned, the more liable are they to croup. After puberty it scarcely ever occurs. Some families, those especially in which the children are of a sanguineous temperament and full habit, are much more liable to the disease than others. It often attacks children who have not fully recovered from a previous illness. It is liable to recurrence, at distant intervals, upon exposure, not merely to an atmosphere which has been influenced by passing over a large body of water, but to any of the causes which produce common catarrh. Hoarseness, in very young children, does not usually attend common catarrh ; and hence when * Ce fut an quartier general de Finkenstein le4 Juin, 1607, que S. M. I et K. donna I'ordre d'ouvrir un con- cours sur la maladie cnnniie sous le nom de croup; et cVst en execution de cet ordre que son excellence Mon- «eimptoins m.ist have lined the upper part of tile windpipe as well as the fauces: this exudation, as it nppear-d on the fauces, wu considered to be a slomrh, the discovery of Bretonneau not having been made Many vears after, three children, also in one family, were affrcted in a similar manner, during a similar epi- demic constitution, two of whom died. These cases were not attended with an efflorescence of td- skin, nor were they traced to contagion, but we ciiuiiot affirm that the disease was not epidemical. At the period i.f the occurrence of the last three cases, a Minilar incrustation often covered the fauces of those who were labouring under gastric fever, to which dis- easowe were inclined to think that this angina was allied. 2v objection by calling the attention of the reader to the following passage in Laennec, wherein a dis- ease, which is either cynanche or maligna or an ideal affection, is upon the authority of MM. Guersent and Bretonneau termed croup. " In some cases of croup, such as occur in hospitals, the state of the system is very different, there be- ing evident marks of a septic change in the fluids of the body : the pulse is but little accelerated, the skin harsh and dirty, the debility extreme, and the breath fetid, even when no gangrenous specks appear: this variety is, by Guersent and Bretonneau, denominated asthenic. Asthenic croup would seem occasionally to be propagated by infection." Asthenic croup! croup with an unaccelerated pulse, fetid breath, and propagated by infection!—Laennec, after describing croup, talks of that affection resulting from a gangrenous angina, in which eschars are distinguishable before the appearance of the false membrane, and in which the gangrene is indicated by its peculiar odour. If the disease of M. Bretonneau be not cynanche maligna, let it henceforth be known as diphtherite plastic angina, angine couenneuse, or angina membranacea, or let the next observer invent a new name more to his taste ; only let him not term it croup, which is a title already applied to an affection of a very different kind, which belongs to another order of diseases. [Almost all pathologists admit, that the essen- tial character of croup is a violent laryngo-tra- cheitis, with tendency to the exudation of plastic lymph; but the generality of British and Ameri- can practitioners regard it to be very different from the diphtheritic inflammation that occurs in diph- theritic stomatitis and pharyngitis, described by Bretonneau and Laennec. In primary croup, as it has been termed by Dr. Stokes, the accom- panying fever is symptomatic. It is this which is met with in childhood; whilst secondary croup is a symptomatic affection, and is the croup of the adult—the diphtherite of Bretonneau. Between these two forms of croup Dr. Stokes has pointed out the following differences : PRIMARY CROUP. 1. The air passage! primarily en- F>S"1- 2. The fever symptomatic of Che local disease. 3. The fever infliromat-ry. 4. Necessity fur antiphlogistic treatment, and the frequent success of such tiealment. 5 The disuse sporadic, and, in cen.nn si ua:inns, endemic, bu' ne- ver contagious. 6. A disease principally of child- hood. 7. The exudation of lymphspread- ing io the glottis, from below up- wards. 8. Thr pharynx healthy. 9 11; spha^ia either absent or ve-7 slsht. , 10 Catarrhal symptoms oftenpre- cuisor\ to Ihe laryngeal. II. Complicstin with scnte pul- monary inflammation common. U AKence of any characteristic odour of Ihe breath. SECONDARY CROOP. 1. The laryngeal affec'ion second- ary to disease of ihe pharyux and Uiouth. 2. Ihe local disease arising in the course of another affection, which is generally accompanied by fever. 3. The fever tiphviJ. 4. Incapatnli'y of bearing anti- phlogis'ic Ireilmem; necessity for Ihe Ionic, revulsive and stimulating modes. 5. Thedi-ease constantly epidem- ic, and contagious. [?] 6. Adults commonly affected. 7. The exudation sprpadine to the glottis, from above downwards. 8. The pharynx diseased. 9. Dysphagia common and severe. 10. Laryngeal symptoms super- leniiij without Ihe pre-existence of catairh. 11. Complication with such changes rare 12 Breath often characteristically foe id.] The directions given by Laennec relative to the treatment of croup evince a judgment in this matter, perplexed and distrustful of itself and of the resources of medicine; a disposition to tem- porise, arising, as we may infer, from his concep- tion of the nature of the subject being clouded. 542 CROUP —CYANOSIS. " In doubtful cases," he says, " it would seem preferable rather to omit bleeding than to destroy by injudicious depletion the powers requisite for the separation and excretion of the false mem- brane." As to the question of bleeding in croup when the disease is once established, no doubt ought to exist, unless perhaps we may hesitate with respect to its stage. If the patient is in the first or inflammatory stage of croup, no experi- enced physician will omit bleeding; if in the se- cond, or that of suppuration, no physician will propose it. If it were doubtful to which stage the symptoms belonged, it would be preferable to bleed: the anceps remedium ought to be prefer- red. Bloodletting would probably bring relief if the patient were still in the first stage, and by that measure little would be taken from our hopes were he in the second, from which so few recover. Nothing but the mingling together of incongrui- ties and consequent misapprehensions of croup could have induced an eminent physician like M. Bretonneau to make so dangerous an observation as the following: " I am forced to declare, con- trary to the received opinion, that bleeding in croup has done harm, and accelerated rather than retarded the spread of the coriaceous inflamma- tion. I did not abandon this measure, till after reiterated proofs of ite injurious effects." Physi- cians need not be told not to bleed in cynanche maligna,—it never was their practice to do so, nor would they willingly bleed in any form of mem- branous angina ; but if they renounce bloodlet- ting in the first stage of croup, which they are taught to do by this sweeping dogma of alleged experience, they will part with the best shaft in their quiver. This is no question of nosological subtilty; if so, we would have kept aloof: it is a matter of life and death. We shall conclude these observations with one more quotation from Laennec. " All practitioners who have had occasion to see a good deal of this disease, will readily admit that these measures, al- though very rational and conformable to the re- sults of experience in the treatment of inflamma- tory diseases in general, are nevertheless rarely sufficient, and that very few well-characterised in- stances have yielded to their influence." Such a conclusion naturally flows from an attempt to identify a sthenic and an asthenic disease. The reader may he assured that the practice of medi- cine would be much more satisfactory than it is, were the nature of every disease as well under- stood, the principles of treatment as clear, and the results as uniform as in the instance of genuine croup. If croup is considered as purely an in- flammatory disease, and, in consequence, if the treatment of it be rigidly antiphlogistic, the event, when timely aid is afforded, will be almost inva- riably favourable. If, indeed, the golden oppor- tunity is lost, and the first stage is allowed to pass without proper assistance being given, while the importance of his profession in his own eyes must be enhanced, the physician can accomplish com- paratively little, and the gloomy reflection of Laennec, being modified, may be assented to, namely, that very few well-characterised instances of croup, in the second stage, will yield to the in- fluence of measures even the most rational and conformable to the results of experience. French physicians have of late so honourably and successfully distinguished themselves by their zeal in the prosecution of pathology, that we would readily yield them our confidence, did we not know that such a disposition of mind ought ever to be resisted. The same rule ought to guide our researches into the nature of disease which gov- erns the student in a much higher department of knowledge, viz. " Prove all things;" to which very well may be added on the present occasion, " hold fast only that which is good." T n J. OHEYNE. [Notwithstanding the strong remarks of Dr. Cheyne, the difference between idiopathic or pri- mary, and symptomatic or secondary croup, is now, as before remarked, admitted by pathologists; and hence it becomes necessary to make some ob- servations on the treatment of the latter, or what has been called Croup of the Adult, which is con- nected with the same diphtheritic habit that gives occasion to diphtheritic stomatitis and diphtheritic pharyngitis. The remarks as to pathology and therapeutics, made under the latter disease, are equally applicable to the present. Mercury ad- ministered so as to affect the system, has been given with the view of diminishing the plastic tendency of the blood, and cases are recorded in which severe diphtheritis of the air-passages ap- peared to yield to it. Great reliance has, how- ever, been placed on the topical applications re- commended in diphtheritic pharyngitis, and espe- cially on the muriatic acid, nitrate of silver, and alum, applied in the manner recommended under chronic laryngitis, (q. v.) Tracheotomy has like- wise been advised in diphtheritic Iaryngo-trache- itis, when urgent symptoms arise that threaten suffocation. Perhaps in such cases it might be more serviceable than in primary croup, in which there is so frequently a combination of bronchial and pulmonary inflammation. It has been pro- posed also with another view, to introduce through the aperture the local applications that have been found useful. Fragments of the pellicular exuda- tion have been occasionally expelled through the opening, and through it agents, as calomel, have been introduced to act on the morbid surface. Eight grains of calomel, introduced in this way, appeared to M. Bretonneau to afford marked re- lief in one case. Powdered sugar and powdered alum have been blown into the larynx through the aperture in the same manner. One of the great advisers of topical agents introduced into the larynx, M. Trousseau, seems, however, to have less confidence in them than formerly. They are not much employed. (Practice of Medicine, 2d edit. ii. 247: Philad. 1844.) Robley Dunglison] CUPPING. (See Bloodletting.) CYANOSIS, (icvavos v6ao;,) morbus cxruleus, blue disorder, blue jaundice of the ancients, a morbid appearance which consists in the skin as- suming a blue, purple, or violet colour, especially in those parts where the cutaneous capillary ves- sels are superficial, as on the cheeks and lips. This colour may be a symptom of many differ- ent diseases; but in some instances it is of so marked a purple, and the accompanying symp- toms arc so variable, that most physiologists have CYANOSIS. 548 given this affection its denomination from the colour developed, in preference to one from any assemblage of symptoms; thus constituting the appearance of an idiopathic disease under the ap- pellation of cyanosis. Whether they are justifia- ble in so doing is questioned by others, who con- sider the blue colour as indicative of a cachectic or scorbutic habit, or attributable to other causes. Cyanosis is generally accompanied by difficult respiration, palpitation of the heart with diminu- tion of the natural temperature, an irregular or intermitting pulse, and is often attended with dropsical symptoms, the face especially, in addi- tion to the purple colour, being bloated and oede- matous : all these symptoms are much aggravated by any exertion. When this disorder first attracted the notice of physicians, it was considered to depend on an ul- cerated state of the foramen ovale. A few cases where this imperfection occurred were first ob- served hi young subjects, who survived but a short time, the blue colour being intense, and the arte- rial system supplied with dark venous blood, to the circulation of which through the arteries this tint was attributed. This view was confirmed by the observations of several distinguished anato- mists; Senac, Morgagni, and others, reporting that they had in such instances found free com- munications between the right and left cavities of the heart, which should not have existed. This view appeared to be confirmed by chemical facts, with relation to the blood not having undergone that change in the lungs which vivifies it and fits it for the general circulation ; as well as from the symptoms which those subject to such affections had suffered previous to death,—dyspnoea, dimin- ished temperature, weakness, languor, and an en- gorged state of almost every organ ; symptoms generally associated with a want of the due oxy- genation of the blood in the pulmonary circula- tion. Although cyanosis is often found in connection with an open state between each side of the heart, many cases have also occurred where this imper- fection has been absent, and yet in which all the symptoms of cyanosis have presented themselves. Corvisart was one of the first who put this opinion upon record ; 6tating that a permanent blue colour of the integuments was often connected with an unnatural communication between the cavities of the heart, but that many facts induced him to say we could not always arrive at the same conclu- sion. Several examinations after death occurred to him and others of his contemporaries, in which, 'hough the blue colour had been strongly marked luring life, there was no communication between tie opposite sides of the heart. The writer of tiis article has met with some cases of this de- scription, inso.mu,:h that for some years he began to doubt the necessary connection between the >/ue colour of the skin and such a free communi- «tion. On the other hand, he has seen several Cses where there was a free opening between bth auricles and ventricles which must have sub- waed for many years, and yet in which there was nocyanosts. In one of these cases, which is polished in vol. i. of the Medical Transactions »f »e College of Physicians in Dublin, (New Seri»,) the communications were so large and so free that the heart might be considered single, or consisting of one auricle and one ventricle: in this instance there was no cyanosis. Nearly similar appearances occurred to Fouquier, Bres- chet, and Bertin ; and indeed have occurred to all those who have been conversant with the dis- eased appearances of the heart. One case in par- ticular was met with by Breschet, in which the left subclavian took its rise from the pulmonary artery, and yet there was no blue colour in the parts supplied by the ramifications of that vessel. [A case has been published by Professor Huss, of Stockholm, (Gazette Med. de Paris, 14 Fevr. 1843,) in which there was a communication be- tween the aorta and pulmonary artery without cyanosis; and, more recently, (Edinb. Med. and Surg. Journ.: Oct. 1843,) Dr.Craigie has inferred, from a case related by him, as well as from seve- ral others, first, that the open state of the foramen ovale is rarely a primary and solitary lesion; secondly, that when it is a solitary lesion it is not injurious, and the venous blood of the right auri- cle is not thereby necessarily mixed with the arte- rial blood of the left auricle; and thirdly, that in opposition to what has been hitherto usually taught, the open state of the foramen is, in a large proportion of cases, the means of prolonging life,— an imperfectly oxygenized blood being adequate to maintain vital action. (See Asphyxia.)] It would appear, then, that the mixture of venous with arterial blood will not necessarily produce cyanosis, and that the foramen ovale may be open, allowing this admixture to take place, without the disease in question being the result. Difficult questions, no doubt, will arise with respect to the consequences of the want of oxy- genation in the blood. How is a limb deprived of arterial blood to maintain its heat ? How can it preserve its vitality, or retain its colour .' It is probably because the circulation is free and un- embarrassed, and that there is no obstruction to the depletion of the extreme capillaries. A free and uninterrupted circulation of the blood through the capillary system appears to be necessary to the maintenance of a proper colour in that fluid : stagnation or obstruction impairs it in proportion to its amount. John Hunter included a portion of an artery between two ligatures, thus inducing a stagnation in the intercepted fluid : the result was a change of colour from bright red to purple in the blood thus separated and brought to a state of rest. In all instances also of ecchymosis and petechial extravasion, the effused patches or points assume a purple hue. A partial stasis, then, in the capillaries, whether venous or arterial, on the surface, should more or less exhibit a purple tinge; and such actually takes place in some morbid states not usually noticed. Towards the close of fevers terminating fatally, and in other disorders where the functions of the nervous system are much impeded, and the circu- lation consequently begins to fail, we have often observed the purplish colour in the lips, cheeks, and inside of the mouth ; appearances which may be evidently seen long before death. And what is this but a cyanosed state, induced by a stagna- tion in the capillary system, which now wants 544 CYANOSIS. its propulsive power, when deprived of the ner- vous energy ? All the anatomical observations on this subject, however, confirm the fact, that in every instance of cyanosis examined after death, the right cavities of the heart have been found enlarged, dilated, or thickened, whether there was accidentally an opening or not. Corvisart, in particular, enu- merates a blue or violet colour of the face and lips as appertaining to organic lesions in the right cavities of the heart, and of the whole venous system, which is in a great measure under their guidance. In persons of an advanced age, affected with disorders of the heart, this bluish tint is not un- common, and generally occurs in concurrence with an injected or dark colour of the mucous membranes. In these disorders, towards the close of life, there generally occurs some obstacle to the aortic circulation ; this obstacle is generally con- nected with hypertrophy of the left ventricle; stagnation of blood in the lungs then takes place ; and to this succeeds passive dilatation of the right cavities of the heart. It has been further observed that infants at birth are often cyanosed : this may arise either from the impermeable state of the lungs, or from want of action of the respiratory muscles, especially after tedious and difficult labours. Inflation of the lungs, and other aids, frequently remove this blue tint by exciting respiration. A want, then, of renovated arterial or oxy- genated blood is not the only cause of cyanosis; it appears to depend also on obstructed pulmonary circulation, or other impediments to a free return of the blood to the right cavities of the heart. A bluish or cyanosed appearance on the sur- face is known also to take place when nitrate of silver,has been administered internally ; and this tint has in some instances become permanent. The nitrate, in all probability, is decomposed, and oxide of silver becomes deposited in some part of the superficial cutaneous tissue. The tinge imparted to the skin in liver diseases differs altogether from the violet hue peculiar to affections of the heart. There is a variety of jaundice described by Dr. Baillie, in the Transac- tions of the College of Physicians of London, which he calls the black jaundice, where the colour in some degree approximates to the blue tinge; but in the disease described by him the colour is more of a leaden or sooty character. In some few instances, where there was melanosis of the liver, the tint of the skin has appeared to the writer of this article unusually dark, and differing from the ordinary colour observed in hepatic affec- tions. But in all these instances the distinctive characters are sufficiently striking. The state of the circulation and of the respiration is almost sufficient to afford a diagnosis; and there are other characteristic symptoms sufficiently impressive and well known, which need not be enumerated. Bluish and bruised patches occurring in pur- pura, and in ecchymosed states, do not require notice further than that they are often connected with obstructed circulation in the lungs and through the heart, or with failure in the nervous energy; but for information respecting these the reader is referred to the article Pubpuba. With respect to the treatment of cyanose affec- tions, it is obvious, when it is considered that they depend on organic lesions, that no general plan suited to cure idiopathic cyanosis can be laid down. The radical or complete removal of such disorders is quite beyond the reach of our art. The treat- ment must be palliative, depending of course on the precise mode of lesion in the individual in- stance to be treated. In all cases it is important to maintain a heal- thy, state of the digestive functions by suitable diet and the use of such medicines as regulate the bowels; as the functions of the liver and other organs of assimilation are principally deranged, for want, in some instances, of blood properly renovated in quality, and in others from the cir- culation not being sufficiently free and unobstruct- ed through these organs. Acute pulmonary affections often supervene in subjects of this description; and bloodletting and the other usual aids are required more promptly than in ordinary instances where there is no such complication. But it may be observed that per- sons advanced in life, or even at earlier periods of existence, when weakened by protracted suffering, do not bear sanguineous depletion well. It has been already remarked also, that sufferers from this disease are frequently affected with dilatation of the right cavities of the heart, and that in a passive form; in these cases bloodletting, which, except in cases of excessive sanguineous plethora, affords only momentary ease, is often followed by great prostration of strength. When this disease is attended with dropsical symptoms, the remedies usually resorted to in dropsical affections will afford temporary relief. In those cyanose disorders where the strength is much reduced, the circulation languid, and the temperature below the natural standard, consider- able benefit will be derived from wine, cordials, and stimulants; and opiates will control symptoms arising from tumultuous and irregular action of the heart. It is important to maintain a tranquil state of both mind and body; active exertion is nearly precluded in such disorders, but gestation in the open air is most useful in mitigating the symptoms and prolonging life. [In the Cyanosis of the New-Born, Cyanosis neonatorum, Professor Meigs (Proceedings of the Amer. Philos. Society at the Centennial Meeting, May, 1843) lays great stress on the effect of posi- tion. He recommends that the child should be placed on its right side, with its head and shoul- ders inclined upwards, upon pillows, and be kept in this position for hours. " Upon placing the child thus, its septum auriculorum becomes ) horizontal plane, supporting the blood in the let auricle. The weight of that blood presses tfe valve of the foramen ovale into coincidence wih the plane of the septum, and closes the patulois orifice. The succeeding injections of blood tek< their proper route to the lungs and the system, & that a few acte of the respiratory muscles giv sufficient doses of oxygen to the blood to dimi- ish, and to rapidly remove, the excess of carbtfi and the child is cured." Rest is, doubtless, an important agent in mny of these cases in establishing the circulation fo- perly ; but, on the other hand, a smart blot on CYSTITIS. 545 (See Pa- the breech not unfrequently effects the same ob- ject more speedily. Where the cyanosis is owing to positive malformation, no agency will be of uny permanent advantage. ( Practice of Medicine, 2d edit. i. 489 : Philad. 1844.)] J. Crampton. [CYNANCHE LAPvYNGEA. (See Labyn- GIT1S.)] CYNANCHE MALIGNA. (See Scarla- tina and [Thikiat, Diskasks of thf. ]) CYNANCHE PAROT1DCEA. CSe HOTITIS.) CYNANCHE PHARYNGEA. (See [TuKOAT, DlSEASKS OF THE.]') CYNANCHE TONSILLARIS. (See [Throat, Diseases of the.]) CYNANCHE TRACHEALIS. (See Croup.) CYSTITIS. Cystitis, or inflammation of the bladder, exists in various degrees, from that slightest form which is indicated by an increased secretion of mucus from its lining membrane, to the intensely inflamed state which runs rapidly on to gangrene. Although the several inflamed conditions of the bladder are so intermingled, and pass so gradually one into another, that they re- quire to be viewed in close connection in order to be clearly understood ; yet it is useful, for practi- cal purposes, to distinguish between the highly inflammatory or acute cystitis, and the mild or mucous form to which Lieutaud gave the name, now generally applied to it, of catarrh of the bladder. I. Acute Ctstttis.—Acute inflammation of the bladder is known to exist by burning pain in the region of that organ, pain at the extremity of the urethra, tenderness of the hypogastrium, and frequent calls to void urine, which is expelled in small quantities and with distressing spasms. The local symptoms of inflammation are accom- panied with the usual constitutional disturbance, ushered in by smart shivering, and denoted by frequent tense pulse, hot skin, thirst, loss of appe- tite, constipated bowels, and much restlessness. As the disease advances, the pains shoot from the bladder to the anus, the loins, down the thighs, and even to the epigastrium; complete retention of urine takes place, and the distended bladder is felt as an oval tumour rising tense above the pubes. The tenderness, which was at first con- fined to the hypogastrium, diffuses itself over the whole abdomen; obstinate vomiting of bilious fluid and hiccup take place ; delirium comes on, coma or convulsions at length supervene, and death follows. The urine, during the progress of the inflammation, undergoes several changes. At the commencement it is high coloured, as in other inflammations ; then becomes mingled with flakes of coagulated albumen, or with blood, bloody urine being more especially observed when the disease has been induced by a poisonous dose of cantharides: as the disease proceeds, the urine acquires a highly offensive odour from ite am- moniacal and putrescent condition, resembling more the washings of putrid flesh than human urine. In this brief sketch of the symptoms of acute cystitis, we may trace the progress of the inflam- Vol. I___69 2y» mation from the mucous coat of the bladder, which is the most irritable and the most readily affected by disease, to the muscular tunic, and lastly to the. peritoneal. Anatomists have well remarked that the first of these membranes is but loosely connected by cellular membrane to the second, and this still more loosely to the third; but they have erred in believing that acute disease is not speedily communicated from one to the other. A strong and indissoluble sympathy links them altogether, and renders them prone to follow each other in the train of inflammation. When acute cystitis, instead of commencing within the bladder, is communicated from some of the adjacent parts, as the uterus, the rectum, or the immediately adjoining cellular tissue, the order in which the coats become successively in- flamed will be different; and the muscular or peritoneal coat will then be the first affected. It is rare for the whole mucous membrane to be seized at once with inflammation : most commonly it affects the portion lining the neck of the blad- der,—sometimes the upper fundus, at other times the anterior part, at others the posterior,—and in- volving the orifices of the ureters, it obstructs the entrance of the urine, causes the ureters to become distended, and producing pressure upon the kid- neys, in this manner speedily proves fatal. A slight degree of inflammation, or perhaps we ought to say irritation of a mucous membrane, causes an increased secretion from its surface; a greater converts the natural mucus into a puriform fluid ; and a still higher degree of inflammation replaces the secretions by an effusion of plastic lymph. This progression we find in the inflam- matory affection of many other mucous surfaces besides that of the bladder; of which the exuda- tion of croup, and the false membranes discharged from the alimentary canal and the uterus, are examples. The last change produced in the mu- cous membrane of the bladder by inflammation is gangrene, which sometimes affects the whole surface; at other times it appears in patches; and in either case it is often found that at one spot all the tunics have become sphacelated, perforation has taken place, the urine has escaped into the peritoneal cavity, and thus destroyed the patient. When cystitis is prolonged, the mucous mem- brane becomes ulcerated, and the ulcers, when small, bear no remote similitude to primary syphi- litic sores, by their excavated surfaces and raised margins; a fact which we have had opportunities of verifying by dissection. Ulceration is often more extensive, for the whole interior of the blad- der has been found eroded, and in some instances the muscular fibres of the organ have been ex- posed as if by the knife of the anatomist. When ulceration of the mucous coat deepens and pene- trates through the other tunics of the bladder, it is usually accompanied by the effusion of plastic lymph exterior to the ulcer, which thus glues the neighbouring parts together, and prevents the escape of the urine : but instances have occurred in which an ulcer of the bladder has terminated in perforation, just as from gangrene, though more slowly, and in like manner has proved fatal. The existence of ulceration of the bladder cannot be certainly known during the lifetime of the patient; but there is always reason to suspect it when dis- 546 CYSTITIS. ease of that organ has been of long continuance, when the pain is unceasing and excessive, and when pus is-distinctly detected in the urine. We must not, however, expect to see pus in a separate state, for it is rarely discharged without a copious admixture of mucus -, and this we have known to be the case when dissection revealed ulceration both of the kidney and bladder. Inflammation of the muscular tunic of the bladder may arise either in the membrane itself, or be communicated from the adjacent textures. In some cases the inflammation of this membrane .has induced circumscribed suppuration, (Chopart, Maladies des Voies urinaires, t. i. p. 453 ;) in others the pus has been infiltrated extensively among the muscular fibres (Bonetus, Sepulchre- tum, lib. iii. sect. 23) of the bladder. Extensive abscesses have also been found between the mus- cular and peritoneal coats; and death has in this manner been produced in numerous cases of litho- tomy. Chopart relates a very interesting case of large abscess around the bladder, which occurred in the practice of Moreau. In this case, that dis- tinguished surgeon, after making an opening above the pubes, struck his bistoury into a sus- pected spot near the anus, and formed a counter- opening, by which he succeeded in saving his patient. Inflammation of the peritoneal coat is often the close of a fatal disease of the bladder; but that it takes place under other circumstances, without any dangerous consequences, we have sufficient evidence from the old adhesions not unfrequently found connecting this part to the omentum, to portions of the intestine, to the uterus, or to the rectum. In a recent case of diseased prostate, the omentum was found attached to the peritoneal covering of the upper fundus of the bladder. In all prolonged diseases of the urinary bladder, when frequent ineffectual attempts are made to evacuate its contents, the muscular coat acquires an extraordinary increase of size and firmness, separating into distinct bundles, which project on its internal surface, and leave spaces through which the mucous membrane is forced, thus forming small pouches : this is not the conse- quence of inflammation, but of increased muscular action. There is, however, an indurated and thickened state of the bladder which is produced by inflammation, and of which Frank has given an interesting example, where he was led to con- clude that the whole anterior part of the bladder was in a state of callous induration. (J. P. Frank, De Curand. Horn. Morb. torn. v. Retention. Mu- coso-Lymphat. Vesica.) When acute cystitis is about to terminate favourably, and the violence of the disease has spent its force, the natural mucus of the bladder is increased in quantity and altered in ite appear- ance : it separates from the urine on standing, and forms a ropy gelatinous-like fluid,—the com- plaint passing into that milder form which has been named catarrh of the bladder. Causes.—Acute cystitis is induced by direct injuries, as by wounds, contusions, severe exercise oa horseback, prolonged travelling in a carriage over rough roads, the introduction into the bladder of foreign bodies, as bougies and sounds: the latter are too often incautiously used : indeed to the examinations made under such circumstances may, in some instances, be traced the fatal result of the subsequent operation of lithotomy. Calculi themselves also produce cystitis, commonly of the mild or chronic form, or catarrh of the bladder. All mechanical obstructions to the discharge of the urine, as strictures of the urethra, enlargement of the prostate gland, and calculi lodged in the neck of the bladder, may prove causes of cystitis. It is induced likewise by exposure to cold and moisture, by excess in drinking, by the internal use of cantharides, and even by their application to a highly sensitive and partly abraded surface, as in Ambrose Pare's case of the lady who was cured of an obstinate eruption in the face by blis- tering, (ffiuvres, fol. p. 777.) Cystitis also takes place by continuous inflam- mation spreading along the mucous membrane from the urethra in gonorrhoea, or from the kid- neys when they are diseased. It may likewise be communicated by an extension of inflammation from adjacent parts; from the translation of mi- gratory diseases, as gout and rheumatism; or from the recession of cutaneous eruptions: these are, however, causes of chronic rather than of acute cystitis. Treatment.—The treatment of acute cystitis is to be commenced by free venesection and the warm bath, which may be followed by leeches to the perineum and groins. Should the bladder be much distended, its contents ought to be evacuated without delay, but until some impression be made on the local inflammation, the introduction of the catheter will be exceedingly painful, and produc- tive of no permanent relief. A full dose of calo- mel ought to be given, combined with a grain or two of opium ; and after some hours the bowels may be relieved by castor oil or an emollient ene- ma. Free persprration ought to be kept up by Dover's powder and the cautious use of antimo- nials; while warm opiate fomentations or poul- tices, bags of heated salt, or bladders filled with hot water, are applied to the pubes and perineum. Diluents should be freely given, and the patient restricted to a spare diet of the mildest kind of food. "When cystitis has terminated in the forma- tion of abscess, this ought, if within reach, to be evacuated as early as possible by a free and de- pending opening; while the tendency to hectic is checked by cool air, tepid sponging, and the mineral acids, and the strength of the patient is supported by gentle tonics and light nutritious diet. When ulceration has fairly established itself within the bladder, the resources of our art are rarely of much avail; but we are not war- ranted in assuming that such cases are altogether incurable ; for instances are recorded, and some have come under our own observation, in which health has been restored after calculi and other foreign bodies have escaped by ulceration from the bladder. The sufferings arising from ulcera- tion of the bladder are remarkably mitigated by the full action of calomel and opium, and by the formation of issues over the pubes. Benefit has also been obtained from the administration of uva ursi, pareira bravo, and the weak saline and aerated mineral waters. Of the practice of injecting mucilaginous dilu- ents and mild astringents into the ulcerated blad- CYSTITIS. 547 der, we cannot speak from experience; but we feel strong doubts of its efficacy, and are disposed | to think that the operation would prove irritating and injurious. When acute cystitis has arisen from calculus in the bladder, the obvious remedy is extraction, as soon as the subsidence of urgent symptoms will permit. If cystitis can be traced to the translation of gout or rheumatism, the application of irritants to the situations where these diseases previously existed, and the administration of colchicum, mu6t be had recourse to, while the means already mentioned for subduing inflammation of the blad- der are carefully put in practice. ■II. Chronic Cvstitis.—This form, which has also been called mucous cystitis, and catarrh of the bladder, was at one period considered an uncommon disease; the laborious and accom- plished Hoffmann designated it " rarus vesicae affectus." It exists either in connection with a febrile state of the body, or with simple irritation of the bladder or its adjoining and associated parts. Generally it is met with as a sporadic disease, but like the affections of some other mucous mem- branes, it may prevail epidemically. Gunther describes such an epidemic as prevailing in the autumn of 1782. (Sommering, Ueber die tod- lichen Krankheiten der Harnblase und Harnruhre alter Manner.) Symptoms.—The symptoms of chronic cys- titis are, frequent calls to void urine, with more or less pain in the region of the bladder and at the extremity of the urethra, either before or during the process. There is also, in most cases, tension of the hypogastrium, which may depend either on increased sensibility of the bladder, or on disten- sion from urine. In all cases there is discharged along with the urine an increased quantity of mucus, somewhat altered from its natural appear- ance. Even in health a slight mucous cloud is deposited from the urine in cooling; but in the disease we are now considering, the quantity is greatly augmented, sometimes bearing the enor- mous proportion of more than one-half of the whole fluid discharged from the bladder. (Cho- part, torn. i. p. 415.) It is usually voided sus- pended in the urine, from which after a time it subsides, forming a jelly-like substance, so viscid and tenacious as to be with difficulty detached from the bottom of the vessel. At other times the mucus is discharged from the bladder in a icparate state, and of so thick a consistence as to obstruct the passage of the urine, and even to plug up the catheter. The mucus, which was at first pellucid or grey, becomes in the progress of the complaint yellowish, then greenish, sometimes streaked with blood ; and at length, when ulcera- tion is established, largely mixed with pus. The character of the mucus is always alkaline, and the urine often of the same nature—ammoniacal, sometimes highly fetid. The pathological changes discovered in cases of chronic cystitis are chiefly, injection of the mucous membrane, occasionally enlargement of the veins, and when the disease is of long stand- ing, overgrowth and thickening of the mucous tissue. Ulceration is likewise often observed to have taken place at the close of the disease, when it has been severe and long protracted: on other j occasions acute cystitis has supervened on the I catarrhal affection, presenting after death the usual i marks of the disease. Causes.—Chronic cystitis, or catarrh of the bladder, originates in many and various causes. It has sometimes occurred at the crisis of fevers, as the mode in which solution has taken place ; in other instances it has alternated with mucous discharge from the bronchi. Exposure to damp and cold, and to sudden variations of temperature, has given rise to the disease : it has also, as well as the acute form, originated from the translation of gout and rheumatism, and the repulsion of cutaneous eruptions. But its most frequent causes are calculus in the bladder and enlarge- ment of the prostate gland. It occurs much more rarely among the young than the old, and among females than males,—circumstances which are to be explained by reference to the peculiarities of the female, and to the period at which the pros- tate usually becomes the subject of disease. On more than one occasion we have traced a distinct connection between mucous cystitis and a stru- mous habit; causes having produced it in indivi- duals of this constitution, which would not have been sufficient to excite the disease in those of a more robust constitution. Treatment.—Catarrh of the bladder, though classed with inflammatory diseases, rarely requires the employment of depletion, unless when the pain in the region of the bladder is considerable, and then the application of leeches is usually sufficient. Should the disease appear in connec- tion with other mucous discharges, and be accom- panied with febrile symptoms, the warm bath, the saline mixture, and opiates; and if it have arisen from the translation of gout or rheumatism, or the repercussion of cutaneous eruptions, free perspira- tion, and stimulating the part where the previous disease was fixed, will be proper. In gouty and rheumatic cases the administration of colchicum offers the best mode of cure. When the affec- tion depends on an enfeebled constitution or scro- fulous habit, the mineral acids, bitters and astrin- gents will be found beneficial. Of astringent re- medies the best are pareira brava, uva ursi, kino/ and catechu. But in this form of the disease more advantage is often derived from stimulants of the urinary organs, such as the turpentines, and above all small doses of copaiba and cubeb pepper. [Turpentine, with the catheter kept con- stantly in the bladder, comprised the treatment usually adopted by Dupuytren at one time.] In such cases, also, change of air and sea-bathing on a dry and open shore have been productive of much benefit. The diet ought to be mild and nutritious, consisting of milk, eggs, farinaceous substances, and a moderate proportion of animal food. In almost all instances of this disease, spi- rituous liquors, even in moderate quantity, are in- jurious ; cases however do occur when a small quantity of generous wine will be found beneficial. All irritation of the sexual organs should be avoided ; and if the patient have contracted im- proper habits, they must be abandoned before any hope of cure can be held out. The patient ought to spend much of his time in the open air, using gentle exercise : he should reside, if possible, in a dry and elevated situation, and ought to be al- 548 CYSTITIS —DEAD, (PERSONS FOUND) ways warmly clothed, wearing flannel next the skin. More benefit will otten be found to accrue from a careful adherence to these directions re- garding diet and general management of health, than from the employment of any medicine. The injection of the bladder with mild diluents, such as barley-water, afterwards rendered more stimulant and astringent by the admixture of some mineral water, has been practised and highly recommended by Dessault, Chopart, and others ; and we are inclined to think that advantage may be derived from the mere distension of the mucous membrane under catarrhal disease ; just as gleety discharges from the urethra are cured by the in- troduction of a full-sized sound or bougie. [Where the disease is manifestly connected with an atonic condition of the parieles of the blad- der, the catheter or sonde a demeure becomes indispensable, through which appropriate injec- tions may be sent into the bladder. In the more chronic forms, Sir Benjamin Bro- die has injected nitric acid largely diluted. At first, the proportion ought not to be more than one minim to two fluidounces of distilled water ; but afterwards the proportion may be doubled. The bladder should be first washed out with a little tepid water; the acid solution should then be injected, and be allowed to remain not longer than thirty seconds. This may be repeated at first every two days, and afterwards e\ery day. Should the injection be followed by pain and other evidences of inflammation, or the urine be tinged with blood, the repetition must be postponed. In- jections of tar-water, along with the internal use of turpentine, were highly extolled by M. Dupuy- tren. (La Lannite Franeaise, 8 Avril, 1837.) The iodide of iron would make a valuable injection in such cases. Injections of soot have likewise been used with benefit. (New Remedies, 4th edit.: Philad. 1843.) In very obstinate cases, it has been advised by M. Lallemand to cauterize the interior of the bladder. (See the writer's Practice of Medicine, edit. cit. ii. 73.)] When catarrh of the bladder, &c. depends on the presence of a calculus or other foreign body, no cure can be effected without extracting what causes the irritation ; but after its removal we sometimes find it necessary to administer tonics and urinary stimulants, such as have been already named, before the discharge will cease. And in all cases of this nature the operation should be immediately followed by a careful attention to the state of the cutaneous surface ; and warm clothing should in an especial manner be enjoined. When the disease arises from enlaigement of the prostate gland, the only remedies which can be of avail are those suited to the treatment of that disease. W. Cumin. DEAD, (PERSONS FOUND) — Under this head we propose to treat of those causes by which life is suddenly or quickly extinguished in per- sons previously in the apparent enjoyment of good health. Cases of this kind are peculiarly the objects of legal investigation by the coroner; and as all medical men are liable to be called on to assist him with their professional information and opinion, it is of the utmost importance that clear notions of the true nature of the phenomena that present themselves should be entertained. The object of *sueh inquiry being to ascertain whether death was natural or owing to some ac- cidental cause, the whole subject of sudden death may be conveniently arranged under two heads,— namely, 1. sudden death from natural causes : 2. sudden death from violent causes ; comprehend- ing under the latter every variety, whether the re- sult of accident or of criminal intention. Our first duty on the discovery of a supposed dead body, is to ascertain whether any spark of life still remain, by rekindling which animation may be restored; and this leads us, before enter- ing on the causes and phenomena of sudden death, to consider the states of body that may re- semble death, and to point out the means of dis- crimination between those cases in which life is really extinct, and those in which the exercise of the vital power is only suspended. Nothing is more certain than death; nothing is at times more uncertain that its reality : and numerous instances are recorded of persons prematurely buried, or actually at the verge of the grave, before it was discovered that life still remained ; and even of some who were resuscitated by the knife of the anatomist. Pliny, who devotes an entire chapter to this subject, entitled " De his qui elati revixe- runt," amongst other instances gives that of the Roman consul Avicula, who being supposed dead was conveyed to his funeral pile, where he was reanimated by the flames, and loudly called for succour; but before he could be saved, he was enveloped by the fire and suffocated. Bruhier,* a French Physician, who wrote on the uncertainty of the signs of death in 1742, relates an instance of a young woman, upon whose supposed corpse an anatomical examination was about to be made, when the first stroke of the scalpel revealed the truth: she recovered, and lived many years after- wards. The case related by Philippe Pue is somewhat similar. He proceeded to perform the Cassarean section upon a woman who had to all appearance died undelivered, when the first in- cision betrayed the awful fallacy under which he acted. A remarkable instance of resuscitation after appearent death occurred in France, in the neighbourhood of Douai, in the year 1745, and is related by Rigaudeaux, (Journal des Scavans, 1749,) to whom the case was confided. He was summoned in the morning to attend a woman in labour, at a distance of about a league. On his arrival, he was informed that she had died in a convulsive fit two hours previously. The body was already prepared for interment, and on ex- amination he could discover no indications of life. The os uteri was sufficiently dilated to enable him to turn the child, and deliver by the feet. The child appeared dead also; but by persevering in the means of resuscitation for three hours, they excited some signs of vitality, which encouraged thein to proceed; and their endeavours were ulti- mately crowned with complete success. Rigau- deaux again carefully examined the mother, and * " Dissertation sur l'incertitude des signes de la mort, et Tabus des iiiterrcinens et embauniens prccipiteg." Bruhier mentions 1H0 cases in wliich persons still living were treated as dead; of thesr, 5-> were buried alive, 4 were opened before death, 53 revived spontaneously after being placed in their coffins, and 72 were supposed to have died when they really had not. DEAD, (PERSONS FOUND) 549 was confirmed in the belief of her death ; but he found that, although she had been in that state for seven hours, her limbs retained their flexibility. Stimulants were applied in vain ; and he took his leave, recommending that the interment should be deferred until the flexibility was lost. At five p.m. a messenger came to inform him that she had re- vived at half past three. The mother and child were both alive three years after. There is scarcely a dissecting-room that has not some tra- ditional story handed down of subjects restored to life after being deposited within its walls. Many of these are mere inventions to catch the ever- greedy ear of curiosity; but some of them are, we fear, too well founded to admit of much doubt. To this class belongs the circumstance related by Louis, the celebrated French writer on medical jurisprudence. A patient who was supposed to have died in the Hopital SalpStriere, was removed to his dissecting-room. Next morning Louis was informed that moans had been heard in the thea- tre ; and on proceeding thither he found, to his horror, that the supposed corpse had revived dur- ing the night, and had actually died in the strug- gles to disengage herself from the winding-sheet in which she was enveloped. This was evident from the distorted attitude in which the body was found. Allowing for much of fiction with which such a subject must ever be mixed, there is still sufficient evidence to warrant a diligent examina- tion of the means of discriminating between real and apparent death: indeed, the horror with which we contemplate a mistake of the living for the dead should excite us in the pursuit of knowledge by which an event so repugnant to our feelings may be avoided. Life consists (at least as far as we can perceive,) in the presence of a preserving principle, proper to all organized beings, and peculiar to each spe- cies, which opposes itself continually to the influ- ence of the physical and chemical agents that sur- round us. The effects of these agents in altering the forms and nature of inorganic substances we daily witness, while our frames resist them in every latitude. This power, in conjunction with sensation and motion, constitutes the state of life; a state which subsists as long as this power re- mains. But we do not see this power; it only renders itself sensible by the motions given to the heart, lungs, and other organs ; and it is by the existence of these motions, that we generally judge of the existence of life. This isolated ab- stract principle cannot subsist, as fir as we know, without the instruments by which it makes itself visible; it is for this reason that these are to be particularly considered on the present occasion, without in the least, however, diverting us from the consideration of a great first cause. If life depends upon the presence of a force or power continually opposed to the action of phys caI and chemical laws, real death will be the loss of this force, and the abandonment of organized bodies to these agents ; while apparent death will be only the suspension of the exercise of life, caused by some derangement of the functions which serve as the instruments of vital action. This suspension must last for a considerable time, if we may judge by the ca.ses collected by credible au- thors, to some of which we have alluded, and by the numerous instances of drowned persons re- stored to life after long submersion. From this definition of life and death, it would follow that putrefaction is the only evidence of real death ; but in many instances it would be attended with much inconvenience, and often with danger, to wait for this confirmation of the extinction of life. In malignant diseases, and during times of severe general sickness, the keeping of bodies disinterred until putrefaction announced the reality of death, would be a measure fraught with considerable risk to the lives of the survivors. It then becomes desirable that we should be acquainted with those signs by which we may judge that life is extin- guished by the interruption of its functions. As respiration is a function most essential to life, and at the same time the most apparent, the cessation of it may be considered as an indication of death. But as in certain diseases and states of great exhaustion it becomes very slow and j feeble, so as to the casual observer to appear quite I extinct, various methods have been adopted for , ascertaining its existence. Thus, placing down or other light substance near the mouth or nose ; laying a vessel of water on the chest, as an index of motion in that cavity ; holding a mirror before the mouth in order to condense the watery vapour of the breath; have all been proposed and em- ployed, but they are all liable to fallacy. Down, or whatever substance is employed, may be moved by some agitation of the surrounding air; and the surface of a mirror may be apparently covered by the condensed vapour of the breath, when it is only the fluid of some exhalation from the sur- face of the body. We, therefore, agree fully with the judicious observations of Dr. Paris (Paris and I Fonblanque, Med. Jur. vol. ii. p. 10,) on this sub- ject. " We feel no hesitation in asserting that it is physiologically impossible for a human being to remain more than a few minutes in such a state of asphyxia as not to betray some sign by which a medical observer can at once recognise the ex- istence of vitality; for if the respiration be only suspended for a short interval, we may conclude that life has fled for ever. Of all the acts of ani- mal life, this is by far the most essential and in- dispensable. Breath and life are very properly considered in the Scriptures as convertible terms; and the same synonym, as far as we know, pre- vails in every language. However slow and feeble respiration may become by disease, yet it must always be perceptible, provided the naked breast an<4 belly be exposed; for when the inter- costal muscles act. the ribs are elevated, and the sternum is pushed forward: when the diaphragm acts, the abdomen swells. Now this can never escape the attentive eye: and by looking at the chest and belly, we shall form a safer conclusion than by the popular methods which have been usually adopted." The absence of the circulation of the blood has been looked on as a certain indication of death ; but this is a test not much to be depended on, for it is well known that persons may live even for hours, in whom no trace of the action of the heart and arteries can be perceived. In applying this test, it is necessary to remember that it often occurs that the pulse at the wrist cannot be felt if the limb be extended or everted; but if it is bent, 550 DEAD, (PERSONS FOUND1) and the hand turned inwards, it becomes percepti- ble. We should, therefore, perform this move- ment, by which the artery is relaxed, and the passage of the blood is facilitated when only fee- bly propelled. Sometimes, also, the artery can be felt between the thumb and first metacarpal bone when it is not to be found at the wrist. It is well to seek for the artery at the bend of the arm, as the pulse can often be felt there after it has left the wrist. In these examinations it is necessary to press very lightly, lest we should obliterate the pulsation altogether ; and care should be taken to guard against mistaking the beating of the arteries in one's own fingers for that of the artery under examination. The trial should be made at every part where large arteries pass ; and sometimes the proceeding of laying the body on the left side, and placing the hand under the region of the heart, maybe adopted. The stethoscope may be used with great advantage in these cases, as any mo- tion of the heart will be sure to become sensible through the aid of this instrument. The temperature of the body has also been pro- posed as a guide, but this is very fallacious, as it is well known that the cooling of a body after death is influenced by many circumstances, such as age, habit of body, and the disease of which the person died. With respect to age, it has been observed that the bodies of young persons retain their heat longer than those of old. In fact, in old age, the winter of life as it has been termed, death is scarcely any thing more than to become cold ; and in those cases the temperature of the body is rapidly reduced to that of the surrounding medium. Hence we derive a caution in judging of priority of death among a number of bodies overwhelmed by the same accident; for the body of a young person found warm, and that of an old one found cold, would not indicate that the former had survived the latter. This will be more fully treated of in another article. (See Survi- vorship.) The habit of body has also been observed to exert an influence over the rate of cooling after death, and it is found, cxteris paribus, that fat bodies lose their heat sooner than lean, but putrefy sooner. The disease which has destroyed life is a powerful controlling agent in the loss of tem- perature after death. Thus it has been long known that in apoplexy the body retains its heat for a considerable time. This has been particu- larly noticed by Portal. Again, in that disease or accident frequently witnessed in tropical climates, the " coup de soleil," we are informed by Bade- uoch that the bodies of the sufferers remain warm much longer than in other forms of death. In most kinds of asphyxia except that by drowning, but especially in asphyxia by noxious gases, the dissipation of the animal heat is greatly delayed. In cases of the latter description, Ortila found the heat preserved for twelve hours after death; and we are informed by Samoelowitz, that during the great plague at Moscow, the bodies of those who were speedy victims to that disease preserved their temperature much longer than the bodies of tho>e who die by ordinary diseases. Besides these cases 111 which the animal heat is preserved to an un- usual length of time after death, there are others in which it is rapidly lost during life, and even when there is no danger of death, as in some forms of hysteria, and in syncope. It is also an effect of submersion in water, and is usually ob- served in the bodies of those restored to life after drowning. Flexibility of the limbs succeeding their rigidity is one of the most characteristic signs of death: we say succeeding their rigidity, because so long as the limbs are flexible, if the flexibility has not succeeded stiffness, we may presume that there are some remains of life. We are indebted to Nysten and Louis for some valu- able observations on the occurrence and duration of the cadaverous stiffness. The rigidity of the muscles commences in the trunk and neck; it then spreads to the thoracic extremities, and finally reaches the legs and feet, and in subsiding it follows the same course. Its duration is in pro- portion to the lateness of its occurrence, it being found to continue longer in those cases in which it commences latest. Its energy and duration are always in a direct ratio with the degree of de- velopment and energy of the muscular system at the moment of death : thus it is extremely strong in the bodies of athletic individuals, in those who die of tetanus, or who are asphyxiated by noxious gases whose deleterious action does not affect the contractility of the muscles. In all animals, the moment when stiffness commences is that iu which the vital heat appears to be nearly extinct. Professor Louis, from observations made upon more than five hundred subjects after death, found that at the moment of the absolute cessation of the vital movements, the articulations began to become stiff' even before the loss of animal heat, Fodere has verified the justness of this observa- tion several times in hospitals, and concludes that the flexibility of the limbs is one of the principal bigns by which we may judge that a person is not dead, although there is no other sign of life. During the whole time this contraction of the muscles continues, they resist the action of chemi- cal forces, and it is only when suppleness is re- stored that putrefaction commences. Nysten re- gards this stiffness as a measure of the resistance opposed by organic to chemical forces. Life on the point of extinction seems to take refuge in the muscles, and there causes the spasms we speak of, and during their continuance is able to resist the operation of chemical forces. The occurrence of the cadaverous stiffness is subordinate to the same causes that influence the loss of temperature. We have seen that old age favours the dissipation of animal heat, and in like manner it is observed that the muscular rigidity comes on soonest in the bodies of old persons. The habit of body in which the temperature is longest preserved is that in which stiffness of the limbs is slowest in its invasion; thus the bodies of full and fat persons remain longer flexible than those of meagre and lean. And again, those dis- eases which are followed by a long continuance ol warmth are also remarkable for leaving a corpse in an equal degree flexible ; while those in which the body is rapidly cooled, as haemorrhage for ex- ample, favour the approach of the muscular spasm; and after death from these, the body becomes soon- est and sometimes suddenly stiff'. From this con- currence between the spontaneous cooling of the dead body, and the supervention of the cadaver- DEAD, (PERSONS FOUND.) 551 ous stiffness, it might be presumed that accidental cooling would be followed by a similar effect; and this is precisely what takes place ; for bodies left exposed in cold situations, as on a field of battle, are found to become rapidly stiff. The rigidity of the body is a criterion of great value, as it points out the general contraction of the muscular fibre that occurs shortly after disso- lution.; but in regarding it as a test of death, it is necessary to guard against mistaking the stiffness that arises from other causes for the cadaverous stiffness. In persons frozen but not yet dead, or, in other words, susceptible of reanimation, the rigidity of the body is very great, but on close examination it is found not to be confined to the muscular system, but to pervade all parts of the body. The breasts, belly, and skin, are all equally hard with the muscles, to which alone the stiff- ness is confined in that from death. This, coupled with the crackling noise caused by forcible flexure of a joint, will be sufficient mark of discrimination between the two. Moreover, it can scarcely be a source of error, because it is an effect of the acci- dent to which the person has been exposed,' and if it does not yield to the appropriate remedy (the gradual application of heat), it will be an indica- tion that the subject is really dead. The stiffness that occurs in certain forms of syncope and convulsive diseases can never be confounded with cadaverous rigidity, if proper attention be paid to the facte connected with it; for in the former case it takes place immediately after the invasion of the disease, and always pre- cedes apparent death, while tbe body still pre- serves a considerable degree of warmth ; whereas the cadaverous stiffness is not observed until some time after death, and when the heat of the body is scarcely sensible. In all stiffness of this kind there is much difficulty in moving a limb ; so far it resembles that from death ; but after having bent the limb, on ceasing to apply the force, it immediately flies back to its former position ; while the dead limb, on the contrary, remains in the position in which it is placed. If death really takes place in any of these convulsive diseases, the muscular contraction ceases with the extinc- tion of the nervous influence to which it was owing, and the true cadaverous stiffness succeeds at the proper time, and runs its usual course. But above all, the termination of the cadaverous rigidity in flexibility serves to distinguish it from every other, and is a certain indication of disso- lution. That peculiar cast of countenance termed from its first describer the Hppocratic, has been re- garded by some as another sign upon which reli- ance may be placed in judging of the reality of death. It is thus described by Hippocrates : "The forehead wrinkled and dry ; the eye sunken; the nose pointed, and bordered with a violet or black circle; the temples sunken, hollow, and retired; the ears sticking up ; the lips hanging down ; the cheeks sunken ; the chin wrinkled and hard ; the colour of the skin leaden or violet; the li.drs of the nose and eve-iashes sprinkled with a yeli.nvish white dust." Such is the alteration in the human physiognomy that usually takes place after doatli. But it is also produced by the near approach of death -r often by the sight of imminent danger; and is also commonly observed in criminals at execution, whatever may be the degree of tran- quillity assumed. Moreover, those who perish by sudden death, or of short diseases in which disso- lution is not expected, preserve their usual phy- siognomy ; while, on the other hand, the counte- nance may be pale, ghastly, and contracted in nervous and hysterical affections without extinc- tion of life. Finally, there are some individuals whose integuments during life have a leaden and cadaverous aspect, and whose countenance during natural sleep puts on an appearance little removed from the Hippocratic. From these causes we think that little reliance can be placed on the countenance as a test of death. The changes that take place in the eye after dissolution are remarkable, and have been regard- ed by some authors as satisfactory indications of death. These are, the cornea becoming opaque, and covered with a thin slimy membrane, which breaks in pieces when touched, and is easily re- moved by wiping; and general flaccidity of the eye-ball, which may be perceived by placing the finger on the upper eye-lid and moving it gently over the surface of the eye ; when the point of the finger will sink on coming over the cornea, and a distinct ring will be felt, marking the attachment of this membrane to the sclerotic coat. Certainly these signs are valid in many forms of death, but they do not exist in all, and are therefore not in- fallible. The reason why they are sometimes present and at others wanting, is evident when we consider the causes upon which these changes depend. The cornea owes its brightness mainly to the tension of the eye-ball, produced by a full secretion of the humours. This is proved by evacuating a portion of the humours of a recent eye, when the cornea will become flaccid and opaque; or by taking an eye some time dead, and with the cornea already opaque, and compressing the humours towards the anterior part, when the cornea will reassume its brightness. We find the appearance of the living eye influenced by the same cause, and hence we see the dim cornea in very aged and meagre persons produced by a defi- ciency in the ocular in common with every other secretion. We do not speak of the arcus senilis, but of the general opacity of the cornea observed in such individuals. Hence we can understand why in death after long illness, when the powers of reparation have been for a length of time im- paired, the eye should exhibit its want of fullness by a flaccid and dim cornea. On the other hand, we are led to expect, when death takes place suddenly in a healthy person, that the eye will preserve its lustre for a much longer period ; and this experience confirms ; for it has been observed that after death by apoplexy, asphyxia, prussic acid, &c. the eyes preserve their integrity for a considerable time, owing to their being at the time of death in a state of tension by the due se- cretion of the vitreous and aqueous humours. Moreover, it has been observed that in severe diseases of long continuance, and even in some affections of ttie mind, the eyes have become dim and shrunken, although dentil may not happen, and thus another source of fallacy arises. Different physical tests have been proposed for doubtful cases, such as incisions, burns, blisters, 552 DEAD, (PERSONS FOUND) cupping, flagellation, &c.; but of these it may be said that there are so many instances of disease affecting the nervous system, in which their ap- plication causes no sensation in the sufferer, that they will be still less likely to produce any effect on the sensorium in a body nearly deprived of life. The influence possessed by galvanism in the production of muscular contraction in the living I body has led to its adoption as a test of death; I and with certain limitation it is one of considera- ble value; for although the muscles retain their contractility for some time after absolute death, yet if the death be real, they soon lose it, and be- come insensible to this stimulus. On the other ' hand, if the least spark of life remain, the con- tractility will be also present, and on the applica- tion of the galvanic fluid it will be evidenced by contraction. Galvanism thus becomes a test not of life, but of the reality of death, for if the mus- cular fibre does not obey it, there can be,no doubt that vitality is extinguished. It should be recol- lected, however, that different parts of the mus- cular system retain their contractility, and conse- quently their obedience to the galvanic stimulus, for different periods after death. (Diet, des Sciences Med. art. Mart.) Nysten found, in the body of a guillotined criminal which was given to him im- mediately after execution, that the contractility of the left ventricle was extinguished in forty-nine minutes after decapitation ; that of the stomach, intestines, and urinary bladder continued for fifty- six minutes ; while that of the right ventricle and diaphragm remained for two hours. He found the locomotive muscles lose their contractility in proportion to their free exposure to the atmo- sphere, and those that were not at all exposed continued excitable during four hours; but the auricles of the heart, although in contact with the air during the whole time, did not cease to con- tract, when stimulated for four hours and forty minutes. From many similar opportunities of observation possessed by Nysten, he concludes that the muscles cease to be influenced by gal- vanism after death in the following order : 1. left ventricle ; 2. intestines and stomach ; 3. urinary bladder; 4. right ventricle — this retains its con- tractility under galvanism for one hour ; 5. oeso- phagus, for half an hour longer ; 6. iris ; 7. mus- cles of animal life ; 8. auricles. We have now alluded to the chief criteria of real death; and we may conclude this part of our subject by stating that those most entitled to con- sideration are flexibility subsequent to rigidity of the joints; loss of contractility of the muscles under galvanism; and incipient putrefaction. These are not liable to any important fallacies : the rest are, for the reasons already mentioned, more or less equivocal. It now remains, before we proceed to consider the causes of sudden death, to make a few obser- vations on the changes which the human body undergoes after dissolution ; and we prefer doing so in this place, because the subject naturally follows that which we have j-i-t discussed, and also because a knowledge of th«.- attendant pheno- mena and their causes is often of t.;e highest im- portance to the medical jurist in enabling him to determine the length of time a body submitted to hie inspection may have been dead; or the period at which dissection may he attempted with a prospect of useful results. It is sometimes of the utmost moment to the surviving relatives of an individual found dead, that it shall be determined at what time death took place ; of this a case mentioned by Dr. Male (Elements of Juridical Medicine, p. 101) serves as a good illustration. At the Lent assizes, held at Warwick in the year 1805, a cause was tried in which a gentleman, who was insolvent, left his own house with the intention (as it was presumed from his preceding conduct and conversation) of destroying himself. Five weeks and four days after that period, his body was found floating down a river. A com- mission of bankruptcy having been taken out against the deceased a few days after he had left his home, it became a question of great import- ance to the interests of his family to ascertain whether he was living at that period ; for if it could be proved that he was not, his property would remain untouched by the legal proceedings. From the changes which the body had undergone, it was presumed that he had drowned himself the day he left home ; and to corroborate this pre- sumption, the evidence of Sir George Gibbes of Bath was required, as he had lately been engaged in experiments on the changes produced in animal substances by immersion in water. He stated on the trial that it required five or six weeks to effect changes similar to those observed in the body of this individual; and upon this evidence the jury were of opinion that the deceased was not alive at the time the commission was taken out, and the bankruptcy was accordingly superseded. A few weeks back the writer of this article, in passing along the canal on the south side of Dub- lin, on a Saturday, observed a crowd collected on the bank; on approaching, he discovered the ob- ject of their attention to be the body of a man recently withdrawn from the water. None of the bystanders knew anything of the individual, or of the time at which he had been drowned ; but, from the fresh appearance of the body, the general belief was that he had fallen in the preceding evening. From certain appearances (to be more fully treated of hereafter) the writer was induced to doubt the truth of this supposition, and to assert that the man hid lain in the water for at least five days. An accidental circumstance served to cor- roborate this opinion. Seeing the individual well dressed, and not observing any hat, the writer inquired whether one had been found with him, to which he received a negative answer ; when a boy, who lived in the neighbourhood, came for- ward and mentioned that a hat and handkerchief were found in the water at that place on the pre- vious Tuesday morning, just five days from the time of finding the body. These articles were afterwards proved to have belonged to the de- ceased. This was a case in which, from the appearances presented by the body, very positive testimony could have been given as to the length ot time that had elapsed since death ; and in case any question similar to that in the preceding in- stance was pending, such testimony must have been of the highest importance. The changes that take place in the body after death may be divided into those that occur before and those that follow the invasion of putrefaction. DEAD, (PERSONS FOUND) 553 To the first stage belong diminution of tem- perature, contraction of the muscles constituting cadaverous stiffness, and lividity of certain por- tions of the surface. We have already taken notice of the causes by which the loss of heat and muscular rigidity are influenced, and therefore it is unnecessary to allude to these phenomena at present The extensive lividities usually observed on the back parts of the body shortly after death, are entirely owing to gravitation; the blood, still fluid, and no longer kept in its proper course by an impelling power, obeys the physical law by which it is inclined to seek the most depending .situations, and this takes place in the interior as well as on the exterior of the body ; of which we have examples in the gorged state of the posterior portion of the lungs, and in the vascular turges- cence exhibited by the gastro-intestinal mucous membrane in the lowest part of depending convo- lutions. (Trousseau, Dissertation inaugurate. Pa- ris, 1825.) That all these appearances are the result of gravitation is proved by the fact that we can produce them in other situations by altering the position of the body ; thus, if it be turned on the face, instead of remaining as it usually does on the back, the skin of the face, breast, belly, and anterior parts of the limbs will be found livid, while the back will retain its natural colour, and the congestions in the interior of the body will all be found in the anterior part of the organs. Nay, the lividity, having formed on the back, can be made to disappear, if the body is turned before it becomes cold, and the blood coagulates. Of this the writer has convinced himself by experi- ment. As it has happened that these lividities have been mistaken for the effects of violence, and suspicions of murder having arisen there- from, it is necessary, in judging of such appear- ances, to take into consideration the attitude in which the body may have lain during the first few hours after death, the great extent of surface occupied by them, and the absence of any effusion pr infiltration of blood into the cellular tissue. We shall have to recur to this subject when we come to treat of the effects of blows on the dead body, and their resemblance to the consequences of injuries inflicted during life. The second stage is marked by the occurrence of putrefaction. This is a process peculiar to organized substances, and it seems to follow as a consequence of the manner in which their ulti- mate elements are combined during life. These elements are few in number—oxygen, hydrogen, carbon, and nitrogen constitute the great bulk of organized substances. Other elements, as phos- phorus, sulphur, iron, lime, potassa, and silica, are occasionally present, but in quantities so small as not to invalidate the statement just made. But we find these elements combined in various pro- portions, and thus constituting the different proxi- mate principles of which our bodies are made up, such as fibrin, albumen, gelatine, urea, stearine, elaine, cholesterine, &c, which in composition differ from each other chiefly in the proportion of their component elements. Now these combina- tions are not such as the ultimate elements have the greatest disposition to form ; in other words, their natural affinities lead them to different com- binations and to the production of more permanent Vol. I. —70 2w compounds, namely, water, carbonic acid, ammo- nia, &c. This disposition is controlled by vitality, and as long as it continues, the operation of chemical laws seems suspended ; but as soon as life is extinguished, the elements abandon their former combinations, and enter into new ones, and this constitutes putrefaction. The presence of nitrogen expedites this process, and hence vegetaWe substances, which with few exceptions are deficient in this element, undergo the change | more tardily and imperfectly ; and some animal j substances, as, fats, oils, cholesterine, in which i nitrogen is absent, are little disposed to the putre- factive fermentation. The human body, in common with other ani- mal substances, suffers this dissipation of its prin- ciples after death; but as the phenomena attending this change are not constant as to time, order, and results, it is necessary to inquire into those i causes that influence its course. I The conditions necessary to the speedy putre- faction of a dead body are the exposure to air, moisture, and a moderate degree of heat. The presence of air, however, does not appear to be essential, although its exclusion retards the pro- cess. Putrefaction in vacuo was denied by Gay- Lussac, but some experiments by Guntz of Leip- sic have proved the possibility of its occurrence. He took some pieces of human flesh, and having freed them from any air that might be lodged among the fibres by plunging them into mercury, he passed them into jars inverted over and filled with the same fluid. The flesh rose to the top of the jar, and the apparatus was kept in a moderate temperature. Putrefaction went on, but at a slower rate than if the air had been admitted. In a few days the flesh became soft and pulpy, and of a grey colour. Gas was generated, which was found to be carbonic acid gas, and some highly fetid fluid covered the surface o'f the mercury : the flesh had lost one-third of its weight. He also ascertained that blood alone will purify in vacuo. For this purpose he placed the fore- finger of his left hand under an inverted jar filled with mercury, and then made an incision into the integuments. The blood rose to the top, and in five days it was found to be undergoing putre- faction ; an accident by which the apparatus was upset prevented an analysis of the product. These experiments show that though the presence of air expedites the process, it is not essential. A moderate temperature is a most important condition. If the heat be too high, it prevents the occurrence of putrefaction by rapidly dissipating moisture; and if too low, the process is equally arrested, and, it would appear, from the same cause, — for the fluids being converted into solids by congelation, are as efficiently deprived of the power of assisting putrefaction (so long as they continue in that state) as if they were altogether removed. The practice of packing salmon in ice for the purpose of preserving it fresh during long voyages is a familiar illustration of this point. But the most extraordinary instance on record is the preservation of the mammoth discovered some years ago in Siberia enclosed in a block of ice, on breaking into which the animal was found entire and fresh. This being a specimen of an extinct species of animal, it is of course impossible to cai- 554 DEAD, (PERSONS FOUND) culate the number of centuries it must have been enveloped in its icy tomb. Below 59° Fahren- heit, the process is slowly performed, and at 32° it is altogether suspended. The temperature most favourable to its perfection is from 60° to 80° or 90°. This is the range of the thermometer during our summer, and hence at this time putrefaction most readily goes forward. Moisture is an indispensable condition. This is shown by the readiness with which substances otherwise disposed to putrefy are preserved by drying, as smoked meats, fish, &c.; and still more strikingly by the preservation of animals buried in sand. Caravans in crossing deserts have been overwhelmed by the shifting sands, and the bodies of men and camels have lain for centuries until exposed by the same cause, when they were found dry, shrunken, but without any signs of having undergone putrefaction. Instances of this kind have occurred in Egypt, Arabia, and Persia. Chardin (Traite des Exhumations Juridiques, par MM. Orfila et Leseur, vol. i. p. 382,) mentions the preservation of certain bodies in the sands of Corassan (Persia), where they had been buried two thousand years. It is supposed that the preserving power pos- sessed by some burying-places, as the vaults of the Cordeliers at Toulouse, and those of St. Michan's, Dublin, is owing to the dry and ab- sorbent nature of the surrounding soil. In these situations bodies rarely putrefy, but they undergo a process of natural mummification. The pro- ducts of putrefaction, when conducted under favourable circumstances, are — water, ammonia, carbonic acid, carburetted hydrogen, sulphuretted hydrogen, phosphuretted hydrogen, nitrogen, and hydrogen gases, and there remains a friable matter of a deep brown colour containing the salts of the body and some carbon. From these cursory observations it must ap- pear that the transformation of the dead body will be influenced by the medium in which it is placed. The media existing naturally, and to which all others may be referred, are the earth, air, and water. But as these do not exist in a purely separate state, being found mixed together, —as air impregnated with water, water with air, and earth with both, — the term group may be given to these combinations. Thus we have earthy group, wateryvgroup, and aerial group, by which are meant the combinations usually exist- ing between these media. A group is called cold when the temperature is btlow 32°; cool between 32° and 60°; warm between 60° and 100°; and hot when it is above 100°. The metallic oxydes and salts which enter into the composition of the earth exercise but a small influence in the transformation of a dead body. The action of this medium depends upon the greater or less exactness with which it excludes the access of air and water. Thus sandy soils which quickly absorb water, and argillaceous soils which collect water round a dead body, differ ma- terially in their effects; in the former decomposi- tion goes on slowly, and is sometimes, as we have seen, altogether prevented; in the latter putrefac- tion readily takes place, and sometimes the trans- formation into adipocire is effected. Fresh ground or gardens which are rich in mould, and the soil of church-yards, appear to act as a sort of ferment which assists putrefaction ; for it is found that flesh enters sooner into the putrefactive process when surrounded by substances already under- going that change. We have alluded to the formation of adipocire, and it is necessary, before we leave this part of our subject, to make a few observations on this curious phenomenon. Adipocire, so termed from its resemblance to fat and wax, is a peculiar sub- stance of a soft ductile nature and whitish colour, produced by dead animal substances undergoing decomposition under particular circumstances. We are indebted to Fourcroy for the first scienti- fic account of this peculiar transformation. His attention was directed to it on the occasion of the celebrated exhumations practised at the ancient burying-place Des Innocens at Paris, in the years 1785, 86, 87, when from fifteen to twenty thou- sand bodies were removed for the purpose of era- dicating this cemetery. This spot differed from common burying-grounds, where each individual body is surrounded by a portion of the soil. It was the burying-ground of a large district, where- in successive generations of the inhabitants had been deposited for upwards of three centuries. The remains of the human bodies immersed in this mass of putrescence were found in three dif- ferent states, according to the time they had been buried, the place they occupied, and their relative situations with regard to each other. The most ancient were simply portions of bones irregularly dispersed in the soil, which had been frequently disturbed. A second state, in certain bodies which had always been insulated, exhibited the skin, the muscles, the tendons, and aponeuroses, dry, brittle, hard, more or less grey, and similar to what are called mummies in certain caverns. The third and most singular state of these soft parts was observed in the bodies which filled the common graves or repositories. These were cavi- ties thirty feet in depth, and twenty on each side appropriated to contain the bodies of the poor. Each cavity contained between 1000 and 1500, packed side by side in rows, without any inter- vening earth; so that it might be considered, when filled, as an entire mass of human bodies separated only by two planks of about half an inch thick. The first of these, receptacles opened in the presence of Fourcroy had been closed for fifteen years, the coffins were in good preserva- tion, but a little settled, and the wood had a yel- low tinge. When the covers of several were taken off, the bodies were observed at the bottom, leaving a considerable distance between their sur- face and the cover, and flattened as if they had suffered a strong compression. The linen which had covered them was slightly adherent to the bodies, and with the form of the different regions, exhibited, on removing the linen, nothing but irregular masses of a soft ductile matter of a grey- white colour. These masses environed the bones on all sides, which had no solidity, but broke by any sudden pressure. The appearance of this matter, ite obvious composition and its softness, resembled common white cheese ; and the resem- blance was more striking from the prints which the threads of the linen had made upon its sur face. The grave-diggers asserted that they never DEAD, (PERSONS FOUND) 555 found this matter in bodies interred alone; but that the accumulated bodies of the common graves only were subject to this change. Fourcroy re- marked that the conversion appeared in different stages of advancement, so that in various bodies the fibrous texture and colour, more or less red, were discernible within the fatty matter; that the masses covering the bones were entirely of the same nature, offering indistinctly in all the regions a grey substance, for the most part soft and duc- tile, sometimes dry, always easily separated in porous fragments, penetrated with cavities, and no longer exhibiting any traces of membranes, muscles, tendons, vessels, or nerves. By examin- ing this substance in the different regions of the body, it was found that the skin is particularly disposed to this remarkable alteration. It was afterwards perceived that the ligaments and ten- dons no longer existed, or at least had lost their tenacity, so that the bones were entirely unsup- ported, and left to the action of their own weight. In all the bodies so changed, the abdominal cavity had disappeared. The integuments and muscles of this region being converted into the white mat- ter, like the other soft parts, had subsided upon the vertebral column, and were so flattened as to leave no place for the viscera; and accordingly there was scarcely ever any trace of them ob- served in the almost obliterated cavity. The thorax was also flattened, and its viscera were no longer discernible. Sometimes an irregularly rounded mass was found, which appeared to have arisen from the fat and fibrous substance of the heart. The features of the face were converted into adipocire, and no longer distinguishable, and some of the same matter occupied the cavities of the mouth and orbits. The cranium constantly contained the brain, changed into a similar sub- stance. From various observations, it was found that this fatty matter was capable of enduring in these burying-places for thirty or forty years, and is at length corroded, and carried off by the aque- ous putrid humidity which there abounds. Adipocire, according to M. Chevreul, consists of margaric acid, oleic acid, a little bitter sub- stance, of an orange-coloured principle which tinges the acid, of a trace of odorous principle, of ammonia, very small quantities of lime and potass, and some salts. The alkalies we have mentioned partly saturate the margaric and oleic acids. The latter exists in a very small proportion relatively to the margaric, which abounds in this substance. It is easy to perceive from this analysis that adi- pocire is a soap with double acid and ammoniacal base. Sometimes, however, the acids are found combined with lime. This has been observed when bodies undergo the change in water contain- ing carbonate or sulphate of lime ; and also in earth permitting the infiltration of water which has dissolved these salts in its progress through it. In both cases the ammoniacal soap is first, formed, and is then decomposed by the calcareous solu- tion ; margarate and oleate of lime, and carbonate or sulphate of ammonia being the result. To prove that such is the case, the following experi- ments were made by Orfila and Leseur. On the 4th of December, 1828, they interred a stomach, a portion of skin with the subjacent cel- lular tissue, two testicles, and an omentum, all ' belonging to the human subject. Each of them was enveloped in linen, and placed in a small deal box, which was buried at a depth of two feet and a half. They were disinterred on the 30th of July, 1829, seven months and twenty-seven days after having been deposited in the ground. In place of the stomach they found about half a drachm of adipocire not in the least ammoniacal, but composed of margaric and oleic acids and lime. The skin presented here and there the ap- pearance of adipocire, and furnished on analysis a calcareous soap; the testicles were similarly transformed. The omentum had preserved its as- pect and structure in several places, whilst in others it was changed into a yellowish fatty mass, having the odour of Roquefort cheese, and com- posed of lime and the acids mentioned above. These distinguished experimenters, although pret- ty certain that the presence of the calcareous soap at the expense of the ammoniacal, in these sub- stances, was owing to the rain-water in filtering through the ground having dissolved some of the calcareous salts, which having thus got access to the interior of the wooden box, decomposed the ammoniacal soap, and changed it into calcareous, nevertheless thought it necessary to prove by di- rect experiment that it really was so. According- ly they prepared an ammoniacal soap with pure stearic acid and caustic ammonia, and plunged it into a solution of sulphate of lime. At the end of three weeks, on examining the soap, it was found entirely changed into stearate of lime, and sulphate of ammonia was formed. They made also another experiment: two human stomachs were buried, one in a leaden box enclosed in a wooden one, the other in wood alone: seven months afterwards they were taken up. The stomach contained in the wooden box was trans- formed into a soap partly ammoniacal but chiefly calcareous, whilst that enclosed in the lead offered no trace of saponification, and was but little al- tered. " It is manifest," say they, " that, in this last experiment, the progress of the putrefactive pro- cess had been greatly retarded in consequence of the double envelope, and particularly of the leaden cases; and every thing leads to the conclusion, that if the apparatus had remained under ground as long as was requisite for converting the stomach into soap, this soap would have been of the am- moniacal and not of the calcareous kind." (Traite des Exhumations Juridiques, torn. i. p. 366.) Adipocire is only formed when fat and some azotized substance are found together. The fatty matter furnishes the margaric and oleic acids, and the other the ammonia. This is proved by the following circumstances. Entire dead bodies, or entire parts of a dead body, such as a head, one of the limbs, or the thorax, parts in which are found skin, fat, muscles, &c. are changed into adipocire in stagnant or gently moving water, but isolated muscle furnishes but a small portion of ! this substance, and that only when it is rich in fat. | Fat washed, freed from blood, and separated from parts which contain azote, is not transformed into ! adipocire. Neither does the fibrine of the blood, when perfectly washed and free from fat, undergo the change. Orfila found that portions of skin previously deprived of the subjacent cellular tis- 556 DEAD, (PERSONS FOUND) sue, were not saponified after eight months of in- humation ; while similar portions of the skin of the same individual, to which the cellular substance was left adhering, and buried during the same time, were converted into adipocire. It appears that a sojourn of about three years in the ground is necessary for the complete transformation of a body, and that the change goes forward more quickly in water; and it is only when a number of bodies are buried in the same grave, that the process is perfect, those at the bottom being the first to undergo it. A thick stratum of earth over the grave is necessary, in order to confine the gases given out in the first stages of putrefaction. [A medico-legal question has arisen respecting the length of time which a body must remain in water, in order that this transformation of the tissues may take place. (See the writer's Human Physiology, 5th edit. i. Philad. 1844.) Dr. Gibbs found, that by macerating muscle in water for about a month, he was only able to obtain a small quantity of adipocire. Dr. Harlan observed, that the intesruments of a cranium were, by macera- tion, converted into it in about six weeks ; but in some experiments instituted by Mr. Taylor, (Ma- nual of Med. Jurisprudence, p. 515: Lond. 1844,) the conversion of muscle and fat to adipocire was not complete in stagnant water under two months.] The chief object of the medical jurist to whom a dead body is submitted for inspection, is to as- certain the cause of dissolution. In order to assist in this investigation, we will follow the arrange- ment already proposed. I. Death from Natural Causes.—Death is the inevitable condition to which all bodies that possess life must, sooner or later, be reduced. This termination of their existence forms a grand distinction between organized and unorganized matter. The gradual termination of life, or natu- ral death strictly so called, is very different in its phenomena from the more common or accidental death, fn natural death man expires, as it were, in detail; the external functions and those of the animal life being almost annihilated, whilst those of organic life still remain in vigour. The active powers gradually desert each organ; digestion languishes; secretion, absorption, and capillary circulation are arrested; the general circulation is then suspended in the large vessels ; and lastly, the contractions of the heart cease. In accidental death, the general circulation and respiration are first arrested, while the other functions are suc- cessively and slowly extinguished. So that it has been said that in the former life is first extinguish- ed in the parts, and then ceases in the heart, the influence of death being exerted, as it were, from the circumference to the centre ; while in the lat- ter it ceases first in the heart, and then in all the parts, death proceeding from the centre to the cir- cumference. The termination of life termed na- tural death is a very rare occurrence in the human species in a civilized state : animals often reach it; but the cessation of existence from mere old age has become with us a rare phenomenon. Hal- ler estimates the average probability of human life, and deduces the conclusion that only one in- dividual in fifteen thousand reaches the hundredth year. Accidental death, in contradistinction to natural death, becomes, therefore, an object parti- cularly worthy of attention. This may take place in two ways—either as the slow and gradual ter- mination of a lingering disease; or as the sudden result of some great disturbance of the animal economy, and then called sudden death, as in apo- plexy, hemorrhage, concussion, asphyxia, &c. We now come to consider the natural causes of sudden death, and our observations upon them must be necessarily brief, as it would not be pos- sible to enter into detail upon them in this place; a circumstance not of much consequence, as they are most of them treated of in separate articles through this work. However, we may notice some of the most frequent and remarkable. These are apoplexy, rupture of an aneurism or of a large vessel into one of the cavities; bursting of puru- lent cysts or other collections of fluid, or of blood- vessels into the air-passages; ossification of the valves of the heart; rupture of this organ; as- phyxia idiopathica. Apoplexy may attack at any age, but in the great majority of cases the age is above fifty years : certainly it may be said to be a disease rather of the decline of life. It is a disease which in some instances may be mistaken in its early symptoms, and may terminate fatally in situations which preclude any observation of the event. Those most predisposed are of a full plethoric system, with large head and short neck. Diseases of the blood-vessels of the brain, such as ossifica- tion of the arteries, aneurism, and obstruction of the sinuses, lead to rupture of their coats ; and it is well known that hypertrophy of the heart some- times produces apoplexy. In ordinary cases an examination of the brain sufficiently developes the complaint. Blood is usually found in some part of this organ, rarely on the surface, more commonly in or about the corpora striata or optic thalami, or effused into the ventricles. In old apoplectics who have had many shocks, cysts en- closing clots of blood are found; and the brain surrounding tliem is often observed in different stages of inflammation or ramollissement. (See Apoplexy.) It should be borne in mind that persons seized with apoplexy may fall from a height, and thus bear marks of external injury which might mislead a superficial inquirer as to the cause of death. In cases of rupture of inter- nal aneurisms, or purulent cysts, or of ossification of the valves of the heart, an examination of the body will exhibit the true nature of the disease. The last of the natural causes of sudden death which we have mentioned is that peculiar disease termed by Mr. Chevallier " asphyxia idiopathica." A case of this rare and remarkable affection came under the observation of the writer a few years ago. The subject of it was a healthy woman, forty years of age, in the ninth month of preg- nancy. She complained suddenly one evening of weakness and sickness of stomach, and on making an effort to vomit, she fell back and ex- pired without any struggle. The writer examined the body the following day, and inquired diligent- ly after every cause of death in each of the cavi- ties ; but he never saw more healthy organs, and, taken altogether, certainly never a sounder body. But the state in which the heart was found led to a discovery of the nature of the case. The pa- DEAD, (PERSONS FOUND) 557 rietes of this organ were entire, but quite flaccid, and all its cavities were empty ; while its proper veins were much distended with blood. This so exactly resembled the appearances described by Mr. Chevallier, and the manner of death corres- ponded so fully with that of the cases he men- tions, that it was thought justifiable to refer the cause of death to the disease just alluded to. Mr. Chevallier accounts for death in these cases bv supposing a sudden loss of power in the vessels, chiefly in the minute ones, to return the blood to the heart; in consequence of which this organ, after having contracted so as to empty itself, and then relaxing, continues in that state for want of its accustomed stimulus, and so dies. We men- tion this in order to show that such cases are sometimes to be met with, and that it is necessary to be prepared to detect them. For further infor- mation we must refer to the paper alluded to. II. Deatii from Violent Causes.—The wide extent of this division, and the great importance of the topics included in it, render it of the deep- est interest to the medical jurist. The violent causes of sudden death may be reduced to seven heads, viz. asphyxia, poisoning, wounds, burn- ing, cold, starvation, and lightning. From the very able manner in which the subject of as- phyxia ha»been handled in a former part of this work, little remains to be said upon its general phenomena and theory. (See Asphyxia.) As- phyxia may be defined the suspension of the function of respiration, and consequently of the circulatory and cerebral functions. The inter- ruption may affect primarily either the mechani- cal or chemical phenomena of expiration. The mechanical are the motions of the parietes of the chest, producing inspiration and expiration ; the chemical are the disappearance of oxygen from the air taken into the lungs, the disengagement of carbonic acid gas, and the conversion of the venous into arterial blood. Asphyxia may com- mence by the cessation of either of these classes of phenomena; but in whichever it first begins, it speedily involves the other, and both are soon equally suspended. A violent compression of the thorax, such as is produced by the falling of heavy beams of timber, portions of buildings, roofs of mines, &c. a double wound giving en- trance to the air into both cavities of the chest, rupture of the diaphragm by which the abdominal viscera gain admission to the chest, the effusion of large quantities of fluid into the pleura,—all these put an end to the mechanical phenomena of respiration by interrupting the motions of the thorax. In other cases these motions cease, but from a different cause ; we allude to paralysis of the muscles that move the parietes, which hap- pens when the spinal marrow is cut across, or is j pressed on above the origins of the phrenic nerve, i or above the third cervical vertebra, or when the whole nervous energy is destroyed, as by light- ning. Most commonly, however, it is the second class, or the chemical phenomena of respiration, that cease first; and the motions of the chest are only interrupted because the black blood, which is then driven into all the organs and especially into the muscles and brain, does not carry along with it the power of excitation necessary to carry on the functions of these parts. This interrup- 2w* tion of the chemical phenomena may be produced in various ways : thus sometimes there is total in- terception of the passage of air into the lungs, as when an animal is placed in vacuo, or is smo- thered, drowned, or strangled; at other times, an aeriform fluid does enter these organs, but is not possessed of the principle necessary to act on the blood contained in them, such as azote and hydro- gen gases. It may be that the gas inhaled is en- dowed with deleterious properties; either that it irritates the lungs, as the sulphuric acid gas, mu- riatic acid, and ammoniacal gases ; or that it acts upon the whole animal economy as a poison, such as carbonic acid gas, nitrous acid, carburetted hydrogen and hydro-sulphuretted gases. Thus we find that, by the total interception of all air, or by the inhalation of noxious gases, the chemi- cal phenomena of respiration may be arrested. It is to this we shall direct our attention at present, as the cases in which the mechanical phenomena are first affected are more rare, and will be after- wards considered in treating of death from wounds or bruises, and from lightning. The causes that produce death by asphyxia are drowning, hanging, and strangulation, smother- ing, and the inhalation of noxious gases or air deprived of oxygen. The physiology of Drowning having been already fully discussed in the article Asphyxia, we shaft proceed to consider the medico-legal questions that may arise in the case of a body found in water. These may be arranged under the following heads :—1. whether the body was immersed before or after death ; 2. whether the individual has fallen in by accident, has drowned himself, or has been thrown in by others. 1. The inference that the person was living at the time of immersion is drawn from an attentive examination of the external state of the body, and from a careful anatomical investigation. The body of a drowned person usually presents the following appearances. It is commonly very cold, apparently even colder than the actual tempera- ture ; the limbs are more or less stiff according to the time that has elapsed since death ; the visage is swollen, often dark-coloured, but sometimes pale; the eyes are half open and the pupils dilated ; the mouth is filled with froth ; the tongue is advanced beyond the teeth; and the chest and belly are elevated, the latter being often much distended. This state of the body is common to those who perish in cold clear water, as the sea, rivers, &c.; but the body is sometimes drawn out warm, although death is so complete that anima- tion cannot be restored, the countenance violet- coloured, and the veins of the neck turgid. This happens in drowning in warm fluids or in alco- holic liquids, or in marshes where deleterious gases are disengaged, or when the person has fall- en into the water in a state of intoxication. The ends of the fingers are often found rubbed or scraped, and dirt or sand, of a nature similar to that of the bottom of the water, is perceived under the nails. Coupled with these is the negative sign furnished by the absence of any lesion that could have caused death previous to submersion. The internal appearances disclosed on opening a drowned body are generally the following. The epiglottis is found elevated, and a quantity of 558 DEAD, (PERSONS FOUND) froth fills the trachea and bronchi; the lungs are dilated and gorged with blood; black and fluid blood is found in the right cavities of the heart in a much greater quantity than in the left. The diaphragm is depressed, and water of a nature similar to that in which death took place is dis- covered in the stomach. In the head there is turgescence of the blood-vessels, more or less in- tense as the death has been more or less speedy, and in proportion to the amount of struggling made by the individual. Orfila, (Archives Gen. I de Med. Aout, 1827,) in a memoir read at the Academy of Medicine, has reviewed all the signs given by authors for determining whether immer- sion took place before or after death ; and the con- clusion he draws is, that there is no certain sign of submersion during life but the presence of water, similar to that in which it is found, in the stomach and air-passages; provided that, with reference to the stomach, the water has not been swallowed before submersion, and has not been injected after death : and with respect to the lungs, that the water shall have penetrated to the last uronchial ramifications, and has not been I injected before death ; and that the body shall not have remained long in a vertical position in | the water, so that the water might have entered after death. It would appear from this that we possess two certain signs of submersion during life ; but the restrictions imposed on them are such, that, taken apart from others, they are al- most useless in the great majority of cases. In speaking of water in the air-passages, Orfila must have meant the froth formed by this fluid with the air; for it is very seldom found in substance in this situation. Devergie (Annates d'Hygiene et de Med. Leg. t. ii. p. 432 ; [and Medecine Legale, 2d edit. ii. 392: Paris, 1840] states that in a great number of cases he could find but very slight traces of water in the trachea; and in two only did he observe it in any quantity. Indeed, from the observations of Cullen, (Letter to Lord Cath- cart,) Goodwyn, (Connection of Life with Re- spiration,) and Meyer, (Medical Repository, vol. iii. New Series,) it is plain that a very small quantity of water enters the air-passages in drown- ing ; and this is speedily converted into froth by the motion given to it in the attempt at respira- tion. On the subject of this froth, Devergie makes some interesting observations, the sub- stance of which is as follows :—It is commonly white, consisting of numerous and very small bubbles, constituting a lather rather than a froth properly so called. It never adheres to the tra- chea by mucus, but is in immediate contact with that tube. All the bubbles that form it have a watery envelope, easily broken, and often on opening the trachea the greater part disappear like soap-bubbles. The froth of drowned persons, then, has but little analogy with the expectoration of pneumonia or catarrh; and it is sufficient to have attentively observed it to avoid confounding thein. Its formation necessarily brings with it the idea of vitality, for it cannot take place with- out motion, an impulse communicated to a fluid and a gas in mutual contact. In order to appreciate its mode of formation, and the value that it may possess as a sign of sub- mersion during life, it appears necessary to inquire how it is produced in other cases than asphyxia by submersion. In pneumonia, for example, the individual is induced to expectorate because the extreme bronchial ramifications are filled with mucus, and the air can no longer reach them, and come into contact with the blood to effect the ne- cessary changes. The invalid expels a frothy matter, because the mucus secreted under the in- fluence of bronchial irritation is beaten and mixed up with the air by the alternate and quick efforts of inspiration and expiration, which constitute coughing. The formation of the froth takes place more easily as the irritation is nearer to the last bronchial ramifications, when the tubes, being of a smaller diameter, are more easily obstructed. It is, on the contrary, produced with great difficulty in the trachea, on account of the great dimension of this canal. In drowned persons similar phe- nomena take place, after they have expelled a part of the air contained in their lungs. They are soon solicited by the desire to respire; a small quantity of water enters the trachea, and causes a most distressing stimulus, of which we have a proof in the great suffering experienced by per- sons into whose larynx a drop of fluid has acci- dentally fallen while swallowing; a brisk and sudden expulsion of the water is effected, but it is rarely complete: the portion whrcn remains dissolves a little mucus, and becomes viscid, whilst, at the same time, new inspiratory efforts draw in a new quantity of water : ffom that time the air, agitated with this fluid, rendered more viscid, con- stitutes the froth. This is formed with more diffi- culty in the trachea than in the last ramifications of the bronchi; and consequently we esteem its existence in the superior part of the trachea as a more certain sign of the life of the individual at the moment of submersion than when it is met in the extreme branches. This phenomenon does not leave very durable traces of its existence, for it is sensibly diminished, and even often disap- pears under the influence of putrefaction. The portion of the air-passages where it is preserved during the longest period is at the bifurcation of the trachea. In winter it may be discovered in most cases after eight or ten days, but later it completely disappears. It is true, that if we ex- cept the water contained in the stomach, the other signs of submersion have not a more extended duration. It should be understood that the water I thus taken into the lungs is not, as it was formerly supposed, the true cause of death ; an opinion to which Baron Larrey seems to incline in his Me- | moires. The experiments of Goodwyn have [ shown that a much larger quantity of water than ; that which is found in the lungs of drowned ani- mals, may be introduced into the air-passages without causing death. Thus, he passed into the lungs of a cat, through an opening in the trachea, two ounces of water; a large quantity when com- pared with the size of the animal. It had, imme- diately, difficulty of breathing and a feeble pulse; but these symptoms soon abated, and it lived sev- eral hours afterwards without much apparent in- convenience : after this he strangled it, and found two ounces and a half of fluid in the air-tubes and cells. I The presence of water, then, in the lungs of I drowned persons in the form of froth is to be con- DEAD, (PERSONS FOUND) 559 sidered as an accidental and not essential circum- stance, although it is one of very constant occur- rence. If this fluid is found in large quantity, and in substance, that is, not beaten into froth, the inference would be that it had passed in after death. With respect to the presence of water in the stomach, it has been proved by many authors to be a constant occurrence; and when it is dis- covered in this organ, and is identical with that in which the body is found, it furnishes a strong indication of submersion during life, being a ne- cessary consequence of the act of deglutition. For it has been proved by Fine, Orfila, and Marc, that it is never found in bodies plunged into wa- ter after death, and cannot be made to enter the stomach without the assistance of a tube passed into the oesophagus. [A circumstance, which influences materially the quantity of water contained in the stomach, is the depth of water in which the individual was drowned. This is shown by some experiments instituted by Mr. Taylor. (Elements of Medical Jurisprudence, p. 121.) A cat was lowered to the depth of 55 feet in the Thames ; another was held two feet below the surface. The stomach of the first cat contained a large quantity of wa- ter ; that of the second scarcely any. A third cat was perAitted to rise repeatedly to the surface. The stomach of this cat was distended, but not so much as the one that had been lowered to the depth of fifty-five feet. The influence of pressure of water is, therefore, considerable; and as has been remarked by Dr. Guy (Principles of Fo- rensic Medicine, Part 2, p. 317 : Lond. 1843,) it is probable, that where the water is very deep, the pressure of the fluid may overcome the resistance offered by the collapse of the oesophagus, even although the animal died previously to submer- sion. It is proper to remark, that where water has entered the stomach, it may not be found there after death. If the head be permitted to hang down lower than the stomach, the water will run out. Two cats were drowned in nine fathoms of water. After having remained at this depth for half an hour, they were removed, and suspended with the head downwards. Water drained freely from them, and on examination of the bodies three days afterwards, none was discovered in the stomach or alimentary tube. (Taylor, op. cit.)] From the above-mentioned circumstances the following conclusions are drawn by Devergie : 1. that almost all the signs, taken singly, do not prove that the individual was living at the mo- ment of immersion; 2. that the one which fur- nishes the strongest presumption is the existence of froth placed in immediate contact with the lin- ing membrane of a sound trachea; 3. that this sign acquires a value greater as its situation is nearer to the mouth; 4. that water in the air- passages is a sign of little value, for if it can pen- etrate the trachea after death, and extend even to the last bronchial ramifications, as Orlila has shown, it becomes almost useless; 5. that water in the stomach is one of the most constant, signs, but its value is greatly diminished by the difficulty of proving its identity with the fluid in which the body has been immersed; 6. that if each sign taken singly gives no certainty, the assemblage of all in the same individual may enable a posi- tive conclusion to be drawn. The proofs that death occurred before immer- sion are drawn from the absence of all those signs just enumerated; thus the thorax and abdomen will be found flat,—no excoriation of the ends of the fingers,—no dirt or sand under the nails,—no turgescence of the cerebral vessels,—and no froth in the air-passages. The lungs will be collapsed, and the diaphragm will not have passed the natu- ral line. The stomach will be found not to con- tain any of the fluid in which the body is found, and in addition to these negative proofs, marks of violence may be discovered on the body quite sufficient to account for death. These marks are divided by Fodere, (Med. Leg. torn. iii. p. 112,) into three classes : 1st. those which are totally independent of any connexion with the circum- stances of drowning. Of this nature are the usual signs of poisoning ; a regularly formed ec- chymosis round the neck, indicative of strangula- tion, or wounds inflicted by fire-arms or cutting instruments. All these lesions have an essen- tially distinct character which cannot be mistaken, and hence the evident importance of examining carefully the external appearance of all bodies found in water. It was by pursuing such an in- vestigation that Deveaux discovered, in the body of a woman found in water, a penetrating wound under the left breast, made by a very small instru- ment which had reached her heart. 2dly. Marks of violence which may have resulted from acci- dents attending submersion, or may be caused by previous homicide, such as unequal irregular wounds which do not penetrate far into the body, contusions, fractures, and luxations. In all such cases we should ascertain, if possible, the height from which the individual may have fallen, and the resistance he may have encountered in the fall. The rapidity of the current, and the rough- ness of the banks of a river may also cause ex- tensive wounds. Dr. Fine remarks that the ra- pidity of the Rhone, and the numerous mills erected on its side, often produce most shocking wounds in the bodies which are driven against the stakes in the stream, or are drawn into the machinery. J3dly. There may be lesions received after death. These are to be distinguished from those inflicted during life by the lividity and flac- cidity of their edges, the absence of tumefaction and redness, and want of hemorrhage, or, if the latter be present, by the fluidity of the blood. 2. It being ascertained that the subject was im- mersed while living, it is often of importance to be able to say whether the drowning was the result of accident, of suicide, or of homicide. The solu- tion of these questions is to be obtained by an examination of what may be termed the external circumstances of the case. The locality of the water may be such as to account for the deceased having accidentally fallen into it, or its situation may at once preclude the possibility of such an event. Indications of struggling on the brink, such as tearing of the ground, and many footsteps, together with eci-hyiiio.-es on the person of the deceased, may lead to the supposition of homicide. Thus, in the case of Mr. Taylor, who was mur- dered at Hornsey in December 1818, maiks of footsteps deep in the ground were discovered near 560 DEAD, (PERSONS FOUND) the New River; and on taking out the body, the hands were found clenched, and contained grass which he had torn from the bank. (Paris and Fonblanque, Med. Jur. v. iii. p. 41.) However conclusive the existence of ligatures on the hands and feet of the deceased may ap- pear,— as to the question of the forcible interfer- ence of others, it should be recollected that sui- cides have sometimes adopted such precautions in order to insure their death. There are some in- stances on record, in which the individuals seem to have pursued this course. (Op. cit.) In June 1816, the body of a gauging-instrument maker, who had been missing for some days from his home, was discovered floating down the Thames. On being taken out, the wrists were found tied together and made fast to his knees, which were in like manner secured to each other. He had been in a state of mental derangement for two years. The cord with which he had tied himself was recognised as one that had hung from the ceiling over his bed, by which he used to raise himself up, as he had been confined to bed for some weeks. He was a good swimmer, and it was presumed he had taken this precaution to prevent himself from employing that power. The verdict returned was, «• found drowned." The other instance was that of a man, aged twenty- eight, who with a wife and child was reduced to great distress. On a certain day he took an affec- tionate leave of his family, declaring he would not return until he had procured some employ ment by which he should be able to buy bread for them. The following day his body was taken out of the New River with his hands and legs tied. A card with his address was found in his pocket, and also three-pence; when he left home he had five- pence, and it was supposed he had purchased the cord with the deficient sum ; the verdict brousrht in was "insanity." Another case of a similar nature has been lately published. It was that of a gentleman who was found in the Seine at Paris, having his feet, wrists, and neck tied with a cord. After detailing the appearances of the body, the reporter concludes with the following note: " Mr. X---- had bound his neck, limbs, and hands by means of a rope with slip knots, in order to put it out of his power to aid himself when in the water, and thereby to render certain the execution of his suicide." (Ann. de Hygiene et de Med. Leg. t. ix. p. 207. [See, also, his Medecine Legale: Paris, 1840.]) We mention these cases to show how cautious a medical man should be in forming an opinion in similar instances, and how necessary it is to weigh well every circumstance before he expresses that opinion before a legal tribunal. It is often, as has been already mentioned, of the highest importance to the survivors, that an approximation to the time that has elapsed since death should be arrived at. For assistance in such an investigation, the medical jurist will turn in vain to the systematic works on legal medicine, it being only within the last few years that any ac- curate information on the subject was possessed by the profession. We are indebted to M. De- vergie for the first essay on this interesting sub- ject, one concerning which the most vauue notions were entertained previously to the publication of the memoir alluded to, in the year 1829. The observations of M. Devergie are entitled to much consideration, from the unrivalled opportunity afforded for their formation. He was authorized to carry on his investigations at the establishment called " La Morgue" in Paris, a building on the banks of the Seine, to which are transported ail bodies found dead in the city and ite environs, and where they are exposed during three days for the purpose of recognition by their friends. The number thus exhibited exceeds three hundred an- nually, and includes all manner of violent death*. In case of the sudden disappearance of an indi- vidual, his friends repair to the Morgue, and leave with the porter an accurate description of his per- son, his clothes, and the period at which he was last seen; and when a body is brought in, it u carefully examined, and if it corresponds with any of the descriptions that have been left, notice to that effect is sent to the persons interested, who come and claim it. The number of persons re- cognised is very considerable; in the first six months of the year 1829, out of 148 bodies 116 were claimed. Of this number 62 were drowneck of whom 45 were recognised. Being thus fur- nished with positive information as to the time of immersion and that of finding the body, Devergie was enabled to prosecute his inqairies with great accuracy. He found that in general no change takes place on the exterior before the fourth or fifth day, and the cadaverous rigidity frequently continues two, three, or even four days after im- mersion. This is probably owing to the coldness of the medium in which the body is placed. About the fourth or fifth day, the skin on the palms of the hands begins to whiten, and this change of colour takes place particularly on the ball of the thumb, and the fleshy eminence on the inner side of the palm over the metacarpal bone of the little finger, together with the lateral surfaces of th« fingers. The back of the hand does not partake of this colouring, and the rest of the body pre- sents nothing particular. On the sixth or eighth day, the skin at the back of the hand begins to whiten ; at the same time that the sole of the foot has acquired a similar tinge: the skin of the face is softened, and of a more faded white than the rest of the body. On the fifteenth day, the face is slightly swollen and red ; a greenish spot begins to form on the skin over the middle of the ster- num ; the hands and feet, with the exception of the dorsum of the latter, are quite white, and the skin of the palm of the hand is wrinkled. The subcutaneous cellular tissue of the thorax is red- dish, and the cortical substance of the brain takes on a green colour in the upper part of that organ. At one month, the face is reddish brown, the eye- lids and lips are green and swollen, the neck is slightly green, and a spot of about six inches in diameter, brown in colour and with a green areola, occupies the superior and middle part of the ster- num. The scrotum and penis are enormously distended by gas, the latter being sometimes in a state of erection from that cause. The skin of the hands and feet is quite white and very much wrinkled, presenting the appearance of having been long enveloped in a poultice. The hair and nails are still very adherent. The lungs are em- physematous, and fill the cavity of the chest over- {lapping the heart,—a condition different from that DEAD, (PERSONS FOUND) 561 which these organs present at a more advanced period. At a month and a half, besides the ap- pearances first mentioned, the neck and thorax are found very green, and the cuticle begins to detach itself round the base of the hand where it joins the wrist. At two months, the body is covered with ■lime, which penetrates through the clothes. The face is enormously swelled and of a brown colour, the lips are tumefied and separated so as to ex- pose the teeth. The skin on the middle of the abdomen, as well as that of the arms, forearms, thighs, and legs, is still in a natural state. This is a most remarkable fact, and establishes a strik- ing difference between the progress of putrefaction in water, and when the body is exposed to the atmosphere; in the latter case, the abdomen being the first part to manifest any change. At this period the skin has become detached from the hands and feet, and having the nails attached to it, forms as it were a glove. The skin and nails of the feet are longer in separating than those of the hand. The hair begins to fall off, and is easily removed by pulling. The veins are almost com- pletely empty of blood and commonly distended with gas. The inner surface of the arteries is red, and that of the trachea between the cartilages pre- sents the same colour. If at the moment of death the right cavities of the heart were gorged with blood, the internal surface of the ventricle is of a jet black colour; and in contrary cases an analo- gous appearance is presented on the opposite side. Devergie considers this a most important diagnos- tic mark of death by asphyxia. At two months and a half, the green colour of the skin extends to the arms, forearms, and legs; the nails are completely detached from the hands and feet; some adipocire is formed on the cheeks, chin, breasts, arm-pits, and anterior part of the thighs : the abdomen is greatly swollen by putrefaction within; the muscles at this period preserve their natural colour, and do not appear altered in tex- ture. At three months and a half, there is ob- served destruction of the scalp, eye-lids, and nose, to such an extent as to make it difficult to tell the age of the individual. The skin of the breast is generally of a greenish brown ; the centre of the abdomen is of an opaline colour, and scattered with small ulcerations caused by the water. Larger corrosions are found in different parts of the body. The hands and feet are completely naked of skin. The lungs no longer fill the tho- rax, but leave between them and the pleura cos- talis a space filled with reddish serum. At four months and a half, occurs complete destruction of the face and scalp, leaving the skull bare; the remains of face, the neck, and anterior part of the thighs is entirely converted into adipocire ; and small eminences, indicating the commencement of calcareous incrustation, are observed on the pro- minent parts. The brain presents traces of adipo- cire in its anterior part. Devergie has not classified the changes that take place at more advanced periods. The period from which we have ex- tracted the foregoing account has been severely criticised by Orfila, (Traite des Exhumations Ju- ridiques, t. ii. p. 83,) who endeavours to overturn the facts and doctrine contained in it. But we think he has been satisfactorily and triumphantly replied to by Devergie, (Annates d'Hygiene pub. Vol. I. —71 et de Med. Leg. t. v. p. 429, [and Med. Legale, i. 229,)] who adduces as the best proof of the validity of his conclusions, four cases, in which the periods of immersion, varying from fifteen days to one, two, and eight months, were ascer- tained with the help of his table. As the physiological phenomena observed in persons dead from hanging and strangulation are nearly the same, we shall consider them together in the present section, pointing out the differences between them as we proceed. Notwithstanding the authorities of Boerhaave, Morgagni, and Portal, who imagined that apo- plexy was the immediate cause of death in hang- ing, it is now generally admitted that the event is owing to suffocation. This opinion is confirmed by the experiments of Gregory and Brodie, from which it appears that if an artificial opening be made into the trachea of an animal, below the ligature by which it is suspended, it will continue to live. But we must admit that other injuries are sometimes inflicted, of themselves sufficient to account for death, such as compression of the nerves of the neck, and fracture or dislocation of the spine. With respect to the former, Dr. Paris remarks: "Although the pressure of a ligature on the nerves of the neck cannot be considered as the immediate cause of death in hanging, yet Mr. Brodie has very justly observed that if the animal recovers of the direct consequence of the strangu- lation, he may probably suffer from the effects of the ligature upon the nerves afterwards. Mr. Brodie passed a ligature under the trachea of a guinea-pig, and tied it tight on the back of the neck with a knot : the animal was uneasy, but nevertheless breathed and moved about. At the end of fifteen minutes the ligature was removed ; on the following morning, however, it was found dead. On dissection no preternatural appearances were discovered in the brain, but the lungs were dark and turgid with blood, and presented an appearance similar to that which is observed after the division of the nerves of the eighth pair. «I do not,' observes Mr. [Sir B.] Brodie (manuscript notes), < positively conclude from this experiment that the animal died from an injury to the eighth pair, but I think that such a conclusion is highly probable; and it becomes an object of inquiry whether a patient, having recovered from hanging, may not in some instances die afterwards from the injury of the par vagum.'" (Paris and Fan- blanque, Med. Jur. v. ii. p. 44.) Fracture or dis- location of the spine, when they do take place, must of course contribute to the speedy death of the individual; but these accidents are very rare, even when the fall is great, as in public execu- tions. In numerous instances that have come under the observation of the writer, this cause of death was never observed. As in the case of drowning, two questions present themselves for solution by the medical witness: 1. whether the individual was suspended before or after death ; 2. whether it was an act of suicide or of murder. An individual found suspended may have been killed in different ways; first, he may be hung up after having been murdered ; and again, he may have committed suicide by hanging after having previously tried to destroy himself by other methods, in which he has failed, as by fire-aria* 562 DEAD, (PERS0N8 FOUND) cutting the throat, &c. In the first case we might be led to mistake murder for suicide, and in the second suicide for assassination. It is necessary, then, to be aware of the signs by means of which death by strangulation in general may be distin- guished, in whatsoever manner it may happen. These are lividity and distortion of the counte- nance, protrusion of the eyes, which are frequently suffused with blood, projection and wounding of the tongue by the teeth. The latter depends upon the position of the rope : if it be below the cricoid cartilage, the tongue is pushed out; but if it presses above the thyroid cartilage, it is carried along with the os hyoides backwards. In addition, we have the mark of the cord around the neck forming a livid depressed circle ; the fingers usu- ally bent, the nails blue, and the hands nearly closed, with swelling of the chest, shoulders, arms, and hands, and sometimes ecchymoses in these situations; also semi-erection of the penis, and emissio seminis. Cases of death by hanging occasionally present themselves in which the countenance is pale; this arises from the sudden- ness of death in some individuals, and particularly if the spine be dislocated. On dissection, the body presents nearly the same appearances as those described as caused by drowning, with the exception of water in the air-passages. A bloody mucus issues from the mouth and nose; but this is very different from the froth of drowned persons. The principal vessels of the head and neck are filled with blood, and sometimes ruptured. With respect to the bruised mark of the rope round the neck, it is stated by M. Klein (Journal de Med. prat, de Hufeland, 1815) to be an uncertain sign, —an opinion founded on fifteen cases of suicide by hanging, in all of which it was wanting. Remer, (Annates de Hygiene pub. et de Med. Leg. torn. iv. p. 166,) of Breslau has more lately investigated this subject on an extended scale, and out of one hundred cases collected by him, eighty- nine presented the sugillation on the neck in an evi- dent manner. In one case, instead of ecchymosis, the skin was found of a yellowish brown colour, like parchment; in two others the skin was exco- riated ; in another putrefaction prevented any certain examination; ani] in nine cases it is ex- pressly mentioned that ecchymosis was wanting. It follows from this, that out of one hundred hanged persons, nearly one-tenth were found without a bruised mark. But if this proportion is sufficiently great to induce medical jurists to withhold unlimited confidence in this sign, it is at the same time too small to destroy the validity of the general rule, that such impressions are found in hanged persons. In all the cases that have come under the observation of the writer, the mark of the rope was most distinct. These were all executed criminals, in whom, fiom the nature of the ligature and the height of the fall, such impressions might be expected; but even in the most unfavourable circumstances the ecchymosis has been strongly marked. Remer (loc. cit.) mentions that it has taken place notoriously in those found strangled in a position in which either the feet or the knees had not left the ground. In all the instances observed by us, the ecchymosis did not occupy the part of the skin with which the rope was in contact, but formed two lines on j either side of it, one above, the other below; ! while the intervening portion, the part actually compressed by the cord, resembled dark-coloured : parchment. It is quite necessary that the medical jurist i should not be content with the discovery of a blue ring on the neck, but that he should cut into it, in order to examine the extent of the extravasations, and the injury done to the parts in its neighbour- hood. The height of the fall must cause a differ- ence in the injuries inflicted on the parts com- posing the neck. When the individual falls from ' a considerable height, as in public executions, the lesions produced are very extensive. Dr. Houston (Dublin Hosp. Reports, vol. v. p. 317) has pub- lished an account of some dissections of criminals in whom the similarity of injury is most remarka- I ble. " Both the individuals were strong plethoric men, executed for murder. Their death was evidently caused by strangulation. The cervical vertebrae were unbroken, and the spinal marrow and brain presented no trace of injury. In both, the sterno-mastoid muscle, on the right side (the opposite to that on which the knot of the rope was applied) was ecchymosed, contused and broken; that of the left side was only slightly bruised. The os hyoides and thyroid cartilage were com- pletely severed from each other. The omo-hyoid, sterno-hyoid and thyro-hyoid muscles, were so bruised and lacerated, that only some stretched shreds of them remained to hold the parts together. The thyro-hyoid membrane was also torn across, and the epiglottis, pulled from its root to the back of the thyroid cartilage, had passed up with the os hyoides and tongue into the back part of the mouth. The skin alone remained unbroken, and interposed between the rope and the cavity of the pharynx. This was the only region of the neck which gave evidence of much injury; the great vessels and nerves all escaped unhurt. In two other criminals, which more lately I have had an opportunity of examining, precisely the same effects had been produced by the rope on the soft | parts of the neck, and without any injury to the brain or spinal marrow." The preparations from which the above statement is taken are preserved in the museum of the Royal College of Surgeons, Dublin. The semi-erect condition of the penis, and emission of semen, are signs which, although frequently met with, are not constantly found in hanged persons. Thus Klein, in the memoir alluded to, states he did not perceive them in any of the instances examined by him, and Remer found them only in the proportion of three to four. In some of the cases examined by the writer they were wanting, but in the majority there were evident traces of excitement of the organs of generation. The practice adopted by worn-out libertines, of causing themselves to be half hanged in order to arouse their dormant generative power, is a proof that some effect is produced on these organs by suspension. But as erection is not constantly found in hanged persons, we cannot accord to this phenomenon much value as an indication of death by strangulation, unless when accompanied with other characteristic signs. It adds, then, to the certainty of this kind of [ death, but it is no proof when it exists alone, for 1 it has been found in other forms of violent death; DEAD, (PERSONS FOUND) 563 and its absence is no proof of the contrary. A remarkable proof of the occurrence of this phe- nomenon in hanging is given by M. Guyon, (An- derson's Quarterly Journal of the Med. Sciences, vol. ii. p. 151,) surgeon-major at Martinique, who attended the execution of fourteen persons, with a view of ascertaining the truth respecting the disputed subject of emission. Being situated near them at the place of execution, he observed the penis of all become erect at the moment of stran- gulation, and immediately after five of them made water abundantly. An hour after execution he found in nine of them the penis in a state of semi- erection, and its canal filled with a kind of matter with which the shirt was too profusely impregnated to allow it to be supposed that it came from any other organ than the prostate. [In some experiments made at Lancaster, Pa., upon the body of a criminal executed there in 1839, it was observed, that there was an ejection of fluid from the urethra, but no erection. This fluid when examined afterwards by the microscope, was found to be mucus, and to contain no sper- matic animalcules. (Amer. Journ. of the Med. Sciences, May, 1840, p. 26.)] The second question is, whether it was an act of suicide or of murder. It is admitted by most medical-legal writers that this is a difficult and unlikely method of committing murder, unless the assailants be numerous and powerful. Dr. Smith remarks, " It is perhaps not going too far to say, that a man cannot be hung alive by others, unless his hands be previously tied, and probably his legs also." Accordingly, when a body is discovered hanging, the first impression is usually that the individual has hung himself. But this opinion should not be confirmed until an accurate investi- gation has been made into all the external circum- stances connected with the occurrence. It should first be ascertained that death has been caused by strangulation ; for it has happened that crafty murderers have destroyed their victims in some other manner, and then suspended the body in order to create the suspicion of suicide. But sup- posing strangulation to be recognized, particular attention should be paid to the part of the neck which bears the impression of the ligature, and the kind of mark left by it. Thus, if we find the track of the cord to be low down, and to pass horizontally round the neck, while another and fainter impression exists at the upper part, taking an oblique course, it should excite suspicion that manual strangulation had been resorted to in the first instance, and that the body had been hung up after death. An examination of the dress and person of the deceased will sometimes aid the in- quiries of justice by pointing out the signs of re- sistance and struggling, or robbery. It is neces- sary, however, to judge of any marks of external violence with great caution, for although they may generally be esteemed proofs of homicide, they may have been purely accidental, or have been inflicted by the individual previous to voluntary suspension. De Haen records the case of a per- son who, while hanging, inflicted several wounds on his face; and Ballard (p. 409,) mentions a case of suicide, in which the individual first cut his throat partially. The following interesting case is related by Dr. Male. (Juridical Medicine, p. 243.) « An apprentice-boy in my neighbourhood, working alone in an attic, tied one end of a rope loosely round his neck, whilst his master was from home, probably without any intention of destroying himself, and twisted the other round the projecting part of the top of a door, the planks of which were irregular and somewhat divided; I a small stool, on which he stood, slipped from under him, when he fell forwards, striking his temple against the corner of a box which cut him to the bone; he lay along the floor, his head and shoulders only elevated a few inches above it; the cord not being tied had run nearly its whole length, and then caught between the planks of the door, in which state he died. The wound was magnified by popular rumour into many, and vengeance was denounced against the innocent | master, who was accused of having first killed and afterwards suspended the boy. On examining the boy, the mark of the cord was found to ex- tend from ear to ear; the vessels of the brain were turgid, the thyroid cartilage broken, the nails blue, and the hands firmly closed. From this and other important circumstantial evidence, the coro- ner's jury were convinced that the charge was un- founded." It should be recollected that a person may be hanged accidentally, and therefore the usual verdicts of insanity, or felo de se, are not to be given in all cases where proofs of homicide do not exist, without due caution. A remarkable in- stance of this kind is related by Dr. Gordon Smith, (Principles of Forensic Medicine, p. 236,) which occurred in April 1821, in Northampton- shire. A girl, aged thirteen, was swinging in a brewhouse, and near the rope used by her for that purpose was another for the purpose of drawing up slaughtered sheep. In the course of the exer- cise her head got through a noose of this second cord, which pulled her out of the swing, and kept her suspended at a considerable height until dead. [Mr. Taylor (Elements of Medical Jurispru- dence, p. 173,) relates another case. A boy, ten years old, had been amusing himself by fastening a piece of plaid gown to a loop in a cord which was suspended from a beam in the room. In the I act of swinging he raised himself up, and gave himself a turn, when the loop of rope suddenly caught him under the chin, and suspended him until life was wholly extinct. A playmate wit- nessed the occurrence.] We have said above that it is difficult, without an overwhelming force, to hang an individual against his will; but, on the other hand, it is sur- prising with what facility death may be accom- plished by this means, in situations which at first view would seem to preclude its possibility. The late Prince of Conde, who committed suicide on the 27th of August 1830, was found hanging to a window-shutter, with his feet touching the ground and his knees bent. The attitude in which the body was found raised some suspicion of foul play, and a most accurate investigation of all the circumstances connected with the event was instituted, from which it appeared to have been a case of voluntary suicide. An interesting memoir (Annates de Hyg. pub. et de Med. Leg. tom. v. p. 156,) on the subject, was published in January 1831, in which are related several in- stances of self-destruction by hanging, where the 564 DEAD, (PERSONS FOUND) bodies were found in the most extraordinary | situations and attitudes, accompanied with plates , of the same. In one a man was found in a gran- ary hanging by a cotton handkerchief made fast to a rope which stretched across; the knees were bent, so that the legs formed a right angle back- wards ; the feet were supported on a heap of grain, over which the knees hung at a distance of a few inches. In another, a prisoner was found hang- ing to the bars of a window so low that he was nearly sitting on the ground; he had previously j tied his hands together. In a third, the body was found in a vertical position, with the heels resting j on a window-stool. In the fourth, an English- man, a prisoner in Paris, hung himself in his cell, which was an apartment with an arched roof, and at the lower part of it was a grated window, the highest part of which was not near the height of a man ; nevertheless he hung himself to this grating, and was found almost sitting down, with his legs stretched out before and his hips within a foot and a half of the ground. In a fifth, the at- titude of the body was similar to the first: the man had suspended himself to a large iron pin driven into the wall to support the bed-curtains, and his feet, bent at a right angle, rested on the bed, while his knees approached it within a few inches. In a sixth, the point of suspension was j so low that the person (a female) was obliged to stretch out her legs, one before resting on the. heel, the other behind resting on the toes, in order to accomplish her purpose. In a seventh, a female was found stretched at the foot of her bed, the legs, thighs, and left hip, lying on the floor; the upper part of the body was raised, and suspended by a cord fixed on the neck, and fastened to the hospital-bed. There are other cases recorded in the memoir alluded to, of persons found hung in equally extraordinary situations, but we think it unnecessary to particularize them. A few years ago a man, aged seventy-five, destroyed himself at Castle Carey by fixing a cord round his neck while sitting on his bedside, leaning forward till his purpose was accomplished. His wife, who had for years been bed-ridden, and therefore not likely to have been fast asleep, was in the room during the transaction, and knew nothing of what was going on. (Beck's Med. Jur. by Darwall, p. 283 ; [or 6th edit. ii. 139 : Philad. 1838.)] In order to show the power of the will and firmness of resolution in certain suicides, we quote the fol- lowing case from Remer, (loc. cit.) « Une femme alia, avec l'intention de se pendre, de la chambre ou ses enfans se trouvaient, dans celle oti ils cou- chaient. Sa fille ainee, agee d'environ huit ans, la suivit bientot, et la trouva pendue ; la fille ex- erca tant de tractions sur sa mere pour a detacher, qu'elle y parvient en rompant le lien. Alors la mere, qui avait toujours la corde au cou, repoussa son enfant dan6 la premiere chambre, la repri- manda, et lui ordonna, ainsi du' a ses freres et ses soeurs, de rester ou ils etaient, revint sur ses pas, et se pendit une seconde fois. Les enfans allaient chercher du secoors, mais il n'etait plus temps." From these cases we learn how quickly conscious- ness must be destroyed in this form of death; for were it not so, some exertion would be made by the individuals to save themselves after the expe- riment had been tried to a certain extent. Strangulation, properly so called, differs from hanging in the individual not being suspended; but whether death be caused by suspension or a ligature drawn tight, or by the hand alone, or any other pressure on the trachea, the physiological phenomena are the same. Strangling is a more common method of committing murder than hang- ing, arising from the greater facility with which it is accomplished. A remarkable instance of this is that of Dr. Clench, who was strangled in a hackney-coach in London, in 1692, by two men, who called him out in the night under pretence of taking him to visit a patient. After driving about the city for more than an hour the two in- dividuals left the coach, and the coachman found Dr. Clench sitting in the bottom with his head against the cushion. He was quite dead, and had a handkerchief around his neck, in which was a piece of coal placed just over the windpipe. The coachman had not the slightest knowledge of the transaction, having heard no noise while driving the carriage. The appearances presented by strangled per- sons, when a ligature has been employed, do not differ much from those already detailed, as cha- racteristic of death by hanging. The position of the rope-mark constitutes the chief point of dis- tinction ; if it is not at the upper part of the neck, there can be no doubt the person was not hanged : dislocation of the neck is not to be expected, but the cartilages of the larynx and trachea frequently suffer. The track of the ligature in strangling is horizontal, and usually rather low down on the neck. A question has arisen as to the possibility of strangling being resorted to for the purpose of suicide. Upon this subject Fodere remarks: " Je dirai relativement au second chef de la question, qu'en general les impressions circulaires laissees par la simple strangulation forment seules une presomption d'homicide, parcequ'il n'est guere possible de se donner la mort par ce moyen, les mains cessant de faire force au moment ou la compression commence a s'exercer." (Med. Leg. tom. iii. p. 174.) Notwithstanding this opinion he relates a case communicated to him by Des- granges of Lyons, on which the Society of Medi- cine were consulted, and replied that voluntary strangulation was possible. The case was that of an individual found strangled in a hayloft by a handkerchief which had been tightened by a stick. Another case of a similar description is given by the same author. One of a more recent date is recorded by Dr. Dunlop, (Beck's Med. Jur. by Darwall, p. 290,) on the authority of a navy-sur- geon, a friend of his. A Malay, who on board of a man-of-war in the East Indies had made re- peated attempts to commit suicide, at last succeed- ed by the means alluded to. He tied a handker- chief round his neck, and with a small stick twisted it several times, and then secured it be- hind his ear to prevent its untwisting. Jealousy was the cause assigned for the act. The well- known case of General Pichegru, who was found strangled in prison, in Paris, during the consulate of Buonaparte, gave rise to various suspicions; and the rarity of this form of suicide, together with a general disbelief in ite possibility, served to strengthen the common fame of that day, that he had been thus privately murdered in order to DEAD, (PERSONS FOUND) 565 avoid the risk of a public trial. Certainly the condition in which the body was found seemed to point to such a conclusion. It was lying in bed on the left side, in an easy attitude, with the knees bent, and the arms lying down by the side, with a black silk handkerchief twisted tightly round the neck by means of a stick passed under it. The cheek was torn by the ends of the stick in its rotations. In allusion to this case, Remer (Ann. de Hyg. et de Med. Leg. t. iv. p. 186,) observes : «Je n'ai d'ailleurs ici aucune intention de me constituer le defenseur d"un homme qui a trop verso de sang pour ne pouvoir pas prendre facile- ment sur lui un meurtre de plus. Bien mieux, j'accorde que ce genre de mort n'est que tris rare- merit le resultat d'un suicide, mais je doute que sur cette seule consideration, etsans autres preuves plus fortes, on puisse absolument affirmer qu'il y a eu meurtre." Indeed, when we consider the number of cases, that occur, of suspension, some of which we have mentioned, where the position in which the body is found establishes with what promptitude the loss of sense must have taken place, or how strong the desire of self destruction must have been when the resolution was once taken, we think it is going too far to deny the possibility of death by voluntary strangulation, however cautious we may be in receiving testi- mony on the subject. Persons destroyed by manual strangulation ex- hibit, instead of the circular ecchymosis on the neck, irregular patches corresponding to the fingers of the assailant. We must not expect, however, to find the internal mark of suffocation so distinct as in cases of hanging, because the closing of the air-tube not being so complete, the functions of respiration and circulation go on in some measure for a longer lime. Traces of violence on the chest and limbs are also frequently observed in conse- quence of the struggling and force employed in the act. [In rare cases, strangulation may be accidental. An extremely dissipated, drunken, and disorderly woman went to bed intoxicated, and was found strangled in her bonnet-strings. It appeared that she went to bed with her bonnet on, and falling out of bed, her bonnet became fastened between the bedstead and the wall, and she, being so drunk as to be unable to loosen the strings, was, in con- sequence, strangled. (Guy, op. cit. p. 336.)] Death by smothering is nearly allied to the former. It consists in cutting off the supply of J air to the lungs by forcibly closing the mouth and nostrils. This form of death is more usually ac- ; cidental than intentional, because, unless in the ' case of very young or old feeble persons, it is a difficult method of committing murder. Children ' hive been smothered in bed accidentally, by the nurse or a pillow, overlaying them in such a man- ner as to close the mouth and nostrils. Persons in a state of intoxication may be smothered acci- dentally by falling with the face in mud, shallow water, or the like, and being unable to extricate themselves they perish by suffocation. But drunken persons are also easily destroyed by in- tentional smothering, of which the woman Camp- bell murdered by the notorious Burke and Hare in Edinburgh in 1828, furnishes a melancholy example. This was the last of three charges of 2 x murder laid in the same indictment as having been committed within six months in the same way, and for the same purpose, of supplying sub- jects for the anatomists' dissecting-room; and there is now no reason to doubt that, in conjunc- tion with their two accomplices who turned king's evidence, they had carried on the dreadful trade of human butchery to a far greater extent. The direct evidence of the manner of death, as derived from the testimony of the accomplices, was that Burke and Hare were fighting together, when the deceased, in attempting to part them, was struck down by Hare to a sitting posture on the floor; that Burke, as soon as he had overpowered his companion and thrust him on the bed, threw him- self on the deceased, kept her down by the weight of his body, and covering her mouth and nose with one hand while he applied the other under her chin, held her thus for ten or fifteen minutes till she was dead. The most remarkable appear- ances presented by the body when examined two days after death, were the following:—joints flaccid ; features composed, red, and rather more turgid than natural; lips affected with dark livor; conjunctiva of the eyes, even in the horizontal position of the body, much injected with blood ; a little fluid blood on the left cheek, proceeding apparently from the nostrils; tongue not protru- ded or torn by the teeth ; the scarf skin under the chin much ruffled, and the surface of the true skin dry and brown when denuded, but without blood or surrounding ecchymosis; integuments every where very free of lividity except on the face ; no effusion of blood or laceration of the parts around the windpipe ; no injury, of the car- tilages ; the os hyoides and the thyroid cartilage farther apart than usual, in consequence of stretch- ing of their interposed ligament: on the inside of the windpipe some tough mucus, not frothy, with a few points of blood between it and the mem- brane, which last was healthy ; organs within the chest perfectly natural; the lungs remarkably so, and unusually free of infiltration; blood in the heart and great vessels, and indeed throughout the whole body, very fluid and black, and accumu- lated in the right cavities of the heart and great veins. There were some appearances of violence on the limbs and in the spinal canal, unnecessary to notice, as they were the effects of injuries after death, caused by forcibly doubling up the body to enclose it in a box. Upon this case, Dr. Christi- son (Edinburgh Med. and Surg. Journal, vol. xxxi. p. 243,) (from whose admirable and detailed ac- count we have extracted the foregoing) very just- ly observes: " A conviction has gained ground among the public, and has been encouraged by the sentiments currently expressed in society by some medical men, that the signs of suffocation generally, and as they existed in the body of the woman Campbell in particular, are so obvious and characteristic that they would of themselves, and independently of a knowledge of collateral cir- cumstances, at once attract the attention of a pro- fessional person conversant with anatomy, and excite a very strong and well-grounded suspicion of the cause of death. This idea, if erroneous, must have a pernicious tendency in various ways. A sufficient reason for my taking notice of it is, that it may throw medical inspectors off their 566 DEAD, (PERSONS FOUND) guard, by leading them to expect strongly-marked appearances in every case of death by suffocation. That such appearances are very far from being always present, should be distinctly understood by every medical man. " In the body of the woman Campbell, no per- son of skill, whose attention was pointedly ex- cited by being told that from general circumstan- ces murder was probable, but the manner of death unknown, could have failed to remark signs that would raise a suspicion of suffocation. But if his attention had not been roused,— if, for exam- ple, he had examined it in the anatomical theatre of an hospital, without knowing that suspicions from general circumstances were entertained re- garding it, he might have inspected it even minutely, and yet neglected the appearances in question. Nay, a person of skill and experience would have been more likely to do so than an- other, because every one who is conversant with pathological anatomy must be familiar with such or similar appearances as arising from various natural diseases." For persons found dead from noxious inhala- tions and poisoning, see the articles Asphyxia and Toxicology. Persons found Burned.__In cases where bodies are found dead with traces of extensive burning upon them, the medical jurist, to whom the investigation may be committed, has some delicate and interesting questions to solve. This difficulty has been of late years increased, by the admission of the possibility of spontaneous human combustion, and he is now expected to state—1st, whether burning was the cause of death or not, or, in other words, whether the body was burned before or after death; 2d, whether the burning was spontaneous or ordinary combustion. It is much to be feared that a want of information re- specting the peculiarities of these different cases, has led, even in times not very remote, to the con- demnation of innocent persons. « On a vu dans le courant du dixhuitieme siecle, condamne a perir sur l'echafaud, un malheureux habitant de Rheims, accuse d'avoir assassine sa femme, et de I'avoir ensuite briilee, afin de se dcrober au sup- plice qui l'attendait; et M. Vigrffc a jctte des fleures sur la memoire de l'infortune Millet, dont la femme. sujette a l'ivrognerie, fut trouvee le 20 Fevrier 1725, presque entierement consumee dans sa cuisine, a un pied et demie du foyer." (Fo- dere, Med. Leg. tom. iii. p. 204.) Two cases related by Dr. Christison, (Edin. Med. and Surg. Journ. vol. xxxv. p. 316,) on the authority of the \ late Dr. Duncan, appear to us of a similar nature. In each the prisoner was accused of having mur- dered his wife, and burnt the body afterwards to conceal the murder. " The first was the case of a man, Gilchrist, who was condemned and exe- cuted at Glasgow. The prisoner and his wife lived on tolerably good terms, but used to take fits of rambling and get drunk for days together. At last, on one of these occasions, after their return home in the evening, the people who lived in the floor above them heard a noise like that of two persons struggling, and soon afterwards a rattling or gurgling and moaning, as of one cho- king or bleeding to death. They so strongly suspected that all was not right, that they called I down to Gilchrist through the floor that they | were afraid he was killing his wife. In no long time they were further alarmed by the smell of fire and the filling of the house with smoke; upon which they went down to Gil- christ's apartment and demanded admission. After some delay he admitted them, and in doing so appeared to have come out of an inner room, where he said he was asleep in bed. On letting them in, he stumbled over the body of his wife, who lay in the outer apartment quite dead, kneeling before a chair and very much burnt. In these circumstances the prisoner was accused of having murdered her and then burnt the body to conceal the manner of death; while, on the contrary, he alleged he had gone to bed tired, and knew nothing of what had befallen her till he was awakened by his neighbours, and that he presumed her clothes had caught fire while she was intoxicated and burnt her to death. The medical gentlemen who had been appointed to examine the body, merely reported that they found the body so much burnt that they could learn nothing from it as to the cause of death. The general evidence was all against the prisoner. He was accordingly condemned, although the precise manner of his wife's death was not proved even presumptively, and the sentence was put in exe- cution ; but to the very last he vehemently and solemnly denied that he was guilty." The second case occurred to Dr. Duncan within the same year at Leith. «The general evidence was of the same nature as in the case of Gilchrist, but even stronger against the prisoner. He lived on bad terms with his wife. On the evening of her death she returned home at a late hour with a lighted candle, after getting some whiskey at a neigh- bour's. At this time the prisoner was in bed; but some time afterwards there was heard a consider- able noise, like that of struggling, and of chairs pushed up and down the room ; and after this the man was heard in an adjoining bed-room, endea- vouring to quiet his child, who was crying. Pre- sently the neighbours were alarmed by a strong smell of fire proceeding from the prisoner's apart- ments. At last a man forced his way in by break- ing the window. On entering he found the room full of smoke, and observed something burning red in a corner, over which he instantly threw a pitcher of water, and which proved to be the body of the woman burning on the hearth." Dr. Dun- can was present at the examination of the body under the sheriff's warrant, and reports as follows: " We found some parts of the body, especially the belly, burnt to a cinder. We then examined the parts on which the fire had acted more moderately, namely, the face and extremities, and here there was every mark of vital re-action; some spots were merely red and inflamed; others scorched to a hard transparent crust, but surrounded with dis- tinct redness, and a great many blisters filled with lymph perfectly different from those produced on the dead body, which are not filled with a fluid, but with air or vapour. In short, we found ap- pearances exactly similar to those of fire on a living body, and therefore we reported as our unanimous opinion, that the deceased was burnt to death." As there was no proof of the prison- er's having set fire to her, he was not found guilty, DEAD, (PERSONS FOUND) 567 bat the jury returned the intermediate verdict of I not proven. It is worthy of remark, that although the possi- bility of spontaneous combustion was not mooted at the time of these occurrences, yet the acute mind of Dr. Duncan led him to perceive some- thing extraordinary in the phenomena which pre- sented themselves ; and he particularly comments | upon the violent and destructive action of the fire, j compared with the small quantity of combustible matter consumed. In neither case was there any trace of burning in the house or furniture, and in the last the woman was found on the hearth with part of her clothes unburnt, and a chair from which she had fallen quite entire. She was dead when the neighbours entered, and in the dark the body was discovered by a red light issuing from it. Upon reviewing these cases, particularly the last, we cannot avoid agreeing with Dr. Christi- son, that the body was in that singular state in which it is apt to undergo spontaneous combus- tion ; it being difficult to explain otherwise the great extent of injury inflicted. It is not our in- tention at present to enter into a discussion of the theory of spontaneous human combustion, that sub- ject having been already most fully and ably treated of in a former article, (see Combcstiojj, Spon- taseous); but we wish to direct the attention of practitioners to that interesting phenomenon, in order that they may be prepared to detect it when it occurs ; and we have mentioned the instances just quoted as examples in which a knowledge of this peculiarly morbid condition of body might possibly have saved the lives of innocent persons. Was the body burnt before or after death ?— This question can only be solved by a reference to the phenomena which are known to occur on the application of a burning heat to a living and a dead body, and by observing those indications of vital reaction which are peculiar to the former, and remain visible after life is extinct. We are indebted to Dr. Christison (Edin. Med. and Surg. Journ. vol. xxxv. p. 321,) for some interesting experiments and observations made for the pur- pose of arriving at a more certain knowledge of these phenomena; particularly with a view of as- certaining whether the effects of a burn on a living body can be imitated immediately after death by the application of heat. It appears that the most immediate effect of the application of heat to a living body is a blush of redness to a considerable extent round the burnt part, removable by gentle pressure, disappearing in no long time, and not permanent after death. Next to this in order (according to the author quoted), and occurring most generally at the very same time, is a narrow line of deep rednes's, separated from the burnt part by a stripe of dead whiteness, bounded to- wards the white stripe by an abrupt line of de- marcation, passing at its outer edge by insensible degrees into the diffuse blush already described, but not capable of being removed like it by mo- derate pressure. In every instance in which Dr. Christison watched the effects of the actual cau- tery, as well as in those cases observed for him by others, this deep crimson line appeared in a very few seconds, sometimes in five, generally within fifteen, and once only so late as thirty seconds. Dr. Christison never failed to observe this appear- ance on the bodies of persons burnt a few hours before death, forming a line on the entire skin near the burn, from a quarter to half an inch in breadth, and about half an inch from the burn. Blistering is the next appearance in point of or- der, but it is not a very constant consequence of a burn if life be extinguished a few minutes afterwards. When the heat is applied by means of a scalding fluid, blisters usually appear in a very few minutes. Yet sometimes, in very ex- tensive burns of this kind, especially in young children, there is no vesication at all in many hours. " It follows, then, that the only effects of burns which appear immediately after the injury and remain in the dead body, are, first, a narrow line of redness near the burn not removable by pressure, and, secondly, blisters filled with serum; that the former is an invariable effect; but that the latter is not always observable when death fol- lows the burn in a few minutes." In order to try whether these appearances could be imitated by the application of burning sub- stances after death, Dr. Christison made the fol- lowing experiments: 1. In a stout young man who had poisoned himself with laudanum, a very hot poker and a stream of boiling water were applied to the skin of the chest and inside of the arm one hour after death. 2. A stout young woman died in ten or twelve days of a low typhoid fever, and at her death was but little attenuated. Ten minutes after death boiling water was poured in a continuous stream on the breast and outside of one of the legs. 3. A very powerful, athletic young man poison- ed himself with laudanum. Four hours before death a tin vessel filled with boiling water was closely applied on several parts of the anus, and a hot smoothing-iron was held to the outside of the hip-joint. Half an hour after death a red-hot poker was applied to three places on the inside of the arm. The body was examined in thirty-eight hours. " Some of the spots burnt during life pre- sented a uniform blister filled with serum ; on two j there was no blister, but the cuticle was gone, and the true skin dried into a reddish translucent membrane, at the edge of which there were drops of serum, and also particles of the same fluid dried by evaporation. Round all these spots there was more or less scarlet redness, particularly round the two spots last mentioned. A bright red bor- der, half an inch wide, surrounded the whole burns; and the redness was not in the slightest degree diminished by firm pressure. The spots burnt after death were some of them charred on the surface, and not elevated : two presented vesi- cations, but the blisters were filled with air, the cuticle over them dry and cracked, and the sur- face of the true skin beneath was also quite dry. On the white parts of the skin there was no adja- | cent redness." Similar appearances were pre- 1 sented in the two former experiments to those I now mentioned as the effects produced after death. Three other experiments were made on amputated limbs immediately after operation, with results of a similar nature. From these experiments it appears that the application of heat to the body, even a few minutes only after death, cannot pro- duce any of the signs of vital re-action formerly 568 DEAD, (PERSONS FOUND) described; and that a line of redness near the burn, not removable by pressure, and likewise the formation of blisters filled with serum, are certain signs of a burn inflicted during life. Was the burning spontaneous or ordinary com- bustion ? We have already referred to the article Spontaneous Hdma\ Combustion for an ac- count of this extraordinary phenomenon and its probable causes. It is remarkable that by far the greatest number of victims to this accident are females. Sixteen out of seventeen cases related by Kopp, and all those, amounting to eight, given by Lair, were of this sex. In like manner the four cases mentioned by Dr. Apjohn as having occurred in Ireland, were all old women, and in all the use of spirituous liquors had been carried to a great extent. This kind of combustion pene- trates the body with extraordinary rapidity, and the flame which accompanies it is with difficulty extinguished by water : but although it acts so rapidly and extensively on the body, it is observed that objects in the neighbourhood, unless those in actual contact with it, are not attacked. The trunk of the body is the part that suffers most, being generally almost entirely consumed, while the head and extremities are more spared. The rapidity and depth of these combustions, together with the small quantity of other surrounding com- bustibles consumed, contrast strongly with the slowness observed when bodies are burned on a funeral pile or at the stake, and lead us to under- stand that similar effects cannot be the work of criminal intention, for when burning is resorted to in order to conceal crime, its operations are in- finitely more slow, more imperfect, and extend more to surrounding objects, than in cases of spontaneous combustion. Persons found Dead from Cold. — Death from this cause is by no means rare in countries where the winter is very severe, as we learn from accounts of travellers in Siberia, Lapland, Swit- zerland, &c.: and even in these countries, when the winter is unusually severe, cases occur which equally illustrate the destructive effects of cold. If such accidents happen at a distance from in- habited places, in snow and frost, they are gene- rally too strongly marked by circumstances to be mistaken. But they may occur in populous places, and even in large cities, and are then more liable to misconstruction and suspicion. " The degree of cold necessary for the production of its fatal effects varies in a very remarkable degree with the strength and circumstances of the indi- vidual to whom it is applied, as well as with the rapidity of the cooling process. In some instan- ces we find man enduring an extreme degree of cold with but little inconvenience, whilst in others we see him perishing in a temperature at which water retains its fluidity." (Paris andFonblanque, Med. Jur. vol. vii. p. 950.) There is a very striking description of the effects of cold in the account of the first voyage of Captain Cook. When the Endeavour was off Terra del Fuego, Sir Joseph, (then Mr.) Banks, Dr. Solander, and some others of the company, wished to make a botanical excursion to a mountain that appeared but a short distance from the shore. They set out, twelve in number, including domestics. An intense cold seized them, which they were en- couraged to resist by Dr. Solander, who had cross- ed the mountains separating Sweden and Norway, and knew the fatal effects of yielding to ite influ- ence. He assured them that whoever sat down would sleep, and that whoever slept would never waken. Nevertheless, he was himself the first to yield to the desire for sleep, against which he had warned the rest. He begged to be allowed to lie down ; he stretched himself, and slept some time upon the ground covered with snow, and it was with great difficulty that his friend Banks could rouse him to go a quarter of a mile to a fire which he had lighted. A black servant of Mr. Banks lay down also, replying to the threats of death held out to him, that he only desired to be allowed to sleep and die. Dr. Solander, when aroused at the end of five minutes, had almost lost the use of his limbs, and his feet were so shrunken that his shoes fell off. It was not possible to waken the negro, and he perished with another negro who had been left for a moment with him to assist him. All the persons in the expedition felt the effects of the cold more or less, but the whites were all saved, even Mr. Buchan, a painter, who had a fit of epilepsy, to which he was subject In this example, as well as from more recent observation in the polar seas, it appears that a great degree of cold, particularly when joined with fatigue, produces in the body a stupor and numbness almost insupportable, and that the ardent desire to sleep arising from this stupor is such that it cannot be conquered by the fear of the consequences. We also perceive that men least accustomed to cold are those who most readily sink under its influence, as we find the negroes dying while the whites were saved; and also that strength of mind and body tended much to enable the sufferer to resist, since Sir Joseph Banks, a man endowed with great moral and physical energy, was the one who suffered least of the whole party. The same cause will enable animals to sustain cold with impunity. For in- stance, among hybernating animals, as the dor- mouse and marmot, it has been observed, in experiments made to ascertain the cause of their sleep, that the most vigorous are the most suscep- tible of invigoration by heat; and that they are least readily thrown into a state of slumber by artificial cold during summer. Fodere, who was a Swiss, says that while inhabiting his native mountains, all the cases of death of this nature whose histories he could discover, were of sickly per- sons, children, old men, or females. From the experi- ments of Mr. [Sir B.] Brodie, to ascertain the source of animal heat, it is plain that the temperature of animals is in some way or other dependent upon the integrity of the functions of the nervous sys- tem ; and hence the power of an animal to resist cold will be determined by his power of generating heat. Now it is found that any cause by which the powers of the nervous system are impaired favours the action of cold upon the body; and for this reason an individual labouring under the effects of a narcotic may be killed by a degree of cold that otherwise would have been quite sup- portable. It is for this reason, also, that intoxi- cated persons perish in severe cold more readily than those whose nervous system is not so im- paired. Dr. Paris (loc. cit.) notices two instances DEAD, (PERSONS FOUND) 5G9 that occurred in London, a few winters back, of drunken persons being taken to the watch-house, and there not being any charge against them they were dismissed by the constable of the night, and perished in the streets. A military friend of his communicated to him an instance where, out of a great number of troops who were exposed to in- tense cold, the only one who perished was under the influence of intoxication. This was also ex- emplified on a large scale in the disastrous retreat of the French troops from Russia; for we learn from La Beaume's account that intoxication seem- ed to insure death. Mr. [Sir B.] Brodie is inclined to think that cold probably destroys the principle of vitality equally in every part, and does not exclusively disturb the functions of any particular organ. This opinion is supported by the experiments of Dr. Chassat. In cases of persons found dead from cold, if the accident be recent, attempts may be made to re- store life. The application of heat should be very gradual; and artificial respiration may be tried with a prospect of utility. Internal stimulants should be cautiously administered after signs of returning animation are apparent. Persons found dead from Hunger. — Food being necessary to the maintenance of life, it is plain that its deprivation cannot be endured for any length of time without causing death, and those cases of long fasting, or of refraining alto- gether from food for years, have all turned out to be impositions. It has, however, been ascertained that the want of nourishment is borne differently by different persons, a difference depending on age, health, constitution, sexi &c. Thus, a great number of persons doomed by some calamity at sea or elsewhere to perish by this dreadful death, do not all die at the same time, but some, accord- ing to their constitution, have the sad privilege of surviving their companions in misfortune. Young persons bear hunger worse than old, and sooner sink under its influence,—a fact no less correctly than beautifully illustrated by Dante in his de- scription of the sufferings of Count Ugolino and his children, four in number, all enclosed in a dungeon together, and condemned to death by starvation. The father is represented as surviving until the eighth day, having witnessed the death of his sons in the order of their age, beginning with the youngest. We see that in general, of the two sexes, women bear the privation of food more easily than men; thus, in all accounts of long voluntary abstinence, three-fourths or more of the individuals are of the female sex. Women usually do not consume much, and all being equal as to age and health, they require much less nourishment than men. The power of resisting hunger varies also with the total privation or otherwise of water. Redi (Osservazioni intorno agli Anim. viventi, No. 3, 4,) made many experi- ments to discover how long animals could live without food. Of many fowls that he kept with- out eating or drinking, none passed the ninth day. He gave to one as much water as it chose, of which it drank freely and often during sixteen days, and it did not die until the twentieth. Dogs in like manner lived much longer when allowed water. But it would appear from a number of instances, that the moisture of the atmosphere of Vol. I___72 2x» the place in which an individual may be confined may compensate in some degree for the want of drink. Fodere relates an instance where three women in Piedmont were overwhelmed by snow, and shut up in a narrow stable without any pro- vision for thirty-eight days, and at the end of that time were rescued alive; and he thinks it probable that they owed their preservation to the moisture of the place of their confinement; the absorbents of the skin being thus able to derive a certain portion of the fluid for the use of the system. Chaussier reports the case of some workmen who remained fourteen days without eating or drink- ing, shut up in a deep damp quarry, by the sudden falling in of the roof. They were withdrawn at the end of that time, with a small feeble pulse, scarcely any heat, and just a spark of life remain- ing, which was with difficulty kindled. The ab- sorption of moisture had sustained them, as it did the women at Bergamoletto. A very striking instance of the power of water to prolong life occurred in the case of Luc Antoine Viterbi, who starved himself to death in prison at Corsica. (Pari^p,nd Fonblanque, Med. Jur. v. ii. p. 69.) From the fifth to the sixth day, to hunger insen- sibly succeeded the much more grievous suffering of thirst, which became so acute, that on the sixth, without ever deviating from his resolution, he began to moisten his mouth occasionally, and to gargle with a few drops of water to relieve the burning pain in his throat; but he let nothing pass the organs of deglutition, being desirous not to assuage the most insupportable cravings, but to mitigate a pain which might have shaken his resolution. Until the tenth the thirst became more and more intolerable, when, overcome by excess of pain, he seized the jug of water and drank immoderately. On the thirteenth, the un- happy man thinking himself at the point of death, again seized the jug and drank twice. On awaken- ing on the morning of the fourteenth, and finding his powers restored, he fell into a rage with his keepers, protesting that they had deceived him, and then began beating his head against the wall of his prison, and would inevitably have killed himself had he not been prevented. During the nineteenth, the pangs of hunger and thirst appear- ed more grievous than ever ; so insufferable indeed were they, that for the first time Viterbi let a few tears escape him, but his invincible mind instantly spurned this human tribute. On the twentieth, he declared to the gaoler and physician that he would not again moisten his mouth, and feeling the approach of death he stretched himself, ask- ing, as on a former occasion, whether he was well out, and added, ' I am prepared to leave this world.' Death did not this time betray his hopes. On the twenty-first Viterbi was no more. In this interesting case, which we have here abridged, we perceive the effect of a small portion of fluid in producing vigour in a body worn out by absti- nence. There can be no doubt Viterbi would have died much earlier if he had not made use of the water. In the examination of bodies dead from hunger, the following characters are usually observed. There is general emaciation of the body, together with an acrid fetid odour. The eyes are open and red, the tongue and throat dry, and the intestinal canal is empty. The gall- 570 DEAD, (PERSONS FOUND) bladder is usually filled with bile, which exudes and tinges the neighbouring viscera. The lungs are shrivelled, and all the other organs healthy. It is thought by Fodrre that some conjecture may be drawn as to whether the person has been to- tally deprived of water or not; for, according to the experiments of Dumas, the dogs which he killed by thirst had the viscera inflamed, and the blood thick and coagulated — phenomena which did not present themselves in the bodies of those dead from hunger alone. Persons found dead from Lightning.— Death from this cause is sufficiently common to warrant a consideration of it in this place. Its phenomena may be studied by observing those of common electricity, as it has been sufficiently proved that they are identical. The human body is alike affected by both, and death, whether it be occasioned by the discharge of an electrical bat- tery or by that of a thunder-cloud, exhibits effects precisely analogous. Two theories respecting the manner of death by lightning are extant, the first that of Mr. Hunter, the second of Mr. [Sir B.] Bro- die. Mr. Hunter supposed that when deathis thus occasioned, there is an instantaneous anff total destruction of the vital principle in every part of the body, and that the muscles are therefore re- laxed and incapable of contraction ; that the limbs do not stiffen as after other forms of death, nor does the blood coagulate, and that putrefaction is rapidly set up. On the other hand, Mr. [Sir B.] Brodie concludes from his experiments, given from his manuscript notes by Dr. Paris, (Med. Jur. vol. ii. p. 64,) that an instantaneous extinction of vitality does not take place, but on the contrary the func- tions of the brain are those on which the electric shock exercises its primary influence. In one of his experiments an electric battery of six jars having been charged with electricity, the shock was made to pass through a guinea-pig in the longitudinal direction from the head to the tail. The animal immediately fell on one side insensi- ble, as if stunned; a convulsive action of the muscles of the extremities was observed, but did not long continue, and the function of respiration was not interrupted. In a few minutes sensibility was restored and the animal recovered. In another experiment a shock from nine jars was passed in the same manner through another guinea-pig. The animal immediately fell on one side, exhibit- ed a convulsive action of the voluntary muscles of the limbs, but uttered no cries, and although attentively watched, no signs of respiration could be discovered after the shock had passed through. Three minutes afterwards Mr. [Sir B.] Brodie opened the chest, and found the heart acting with regularity and vigour about eighty times in the minute, and circulating dark-coloured blood. The peristaltic motions of the intestines were also visi- ble, and the muscles obeyed the galvanic stimulus. In this experiment it is plain that neither the irritability of the muscular system at large nor that of the heart was destroyed by the shock, but death took place as from a severe injury of the head and destruction of the functions of the brain. In this case Mr. [Sir B.] Brodie remarks, that if the lungs had been artificially inflated, the action of the heart might have been maintained, and the animal probably restored to life. When a discharge of lightning strikes a human body, it may affect the surface and produce vesi- cations, which most commonly, according to Mayer, pass in the direction of the spine ; or it may penetrate a particular part of the body and act locally. The clothes are not unfrequently torn, and buttons, coin, or other metallic sub- stance melted, but occasionally cases are met with where the clothes are uninjured. Death has sometimes occurred when the thunder-cloud has appeared to be at a considerable distance. This is accounted for by supposing it to be a discharge of electricity from the earth to the cloud, which had become negatively electric, constituting what is termed the returning stroke. All discharges of electricity occur in consequence of the approach of two bodies in opposite states of electrical excite- ment. When a substance excited positively is brought near another in ite natural state and in- sulated, the electric equilibrium of the latter is instantly disturbed, the parts nearest to the former become negative, and the distant ones positive. If the body is not insulated, its electricity passes into the earth, and the whole becomes negatively electric. If, on the contrary, the exciting body be negative, it causes the contiguous parts of a body in its vicinity to become positive. Hence it is established as a law, that an electrified body tends to produce in a contiguous substance an electric state opposite to its own. The electricity developed in this way is said to be induced, or excited by induction. The construction of the Leyden phial is upon this principle; when the inside of the jar is rendered positive by contact with the prime conductor, the outside, if in com- munication with the earth, parts with electricity and becomes negative; both surfaces are therefore electrified, but in opposite states ; and if a com- munication be established between them by a good conductor, the excess of electricity instantly passes along it, and both sides of the jar return to their natural condition. Now when a negatively electric cloud approaches the earth, all objects in its vicinity are positively excited, and when it comes within striking distance, — that is, so near that the tendency of the electricity to pass from the positive to the negative body overcomes the resistance of the intervening portion of air,—the equilibrium is restored with a report and a flash of light, exactly as in the discharge of the Leyden phial. If a person is found in an open place or under a tree shortly after a thunder-storm, with the ordinary appearances mentioned above, we may attribute his death to lightning, and parti- cularly so if the metallic substances about him are found melted and his clothes torn or burnt, while dissection exhibits no other cause of death. Persons found dead from Wounds.—On the trial of Count Koningsmark for the murder of Mr.Thynne, Mr. Hobbs, the surgeon, being pressed by counsel to discriminate between the relative mor- tality of certain wounds found on the body of the deceased, replied, "I believe there never was a wound but it might prove mortal." This is an opinion in which every one who has had oppor- tunities of witnessing a variety of injuries must coincide, from the extraordinary and unexpected results which sometimes follow. Thus, indivi- duals have been known to recover from wounda DEAD, (PERS ONS FOUND) 571- which, from their extent and the importance of the organs implicated, left no room for hope; while others have perished after the infliction of violence so slight, and producing such trivial local effects, as to have almost escaped observation. Such consequences, however, must be considered as exceptions to the usual course observed in similar instances ; and taking wounds in general, we must admit that they allow of classification in reference to their mortality. Any such classifi- cation can never be made complete or definite, from the exceptions just alluded to, as well as from the impossibility of proving the absolute similarity of two wounds, however they resemble each other, when one individual dies and the other recovers, and also from the endless varieties of constitution in different individuals. It is, therefore, upon their usual or more common effects that such a division can be adopted for our present purpose. The term wound, in medico-legal phraseology, is much more comprehensive than the same word in surgery. In the latter it means a solution of continuity : but in the former it also comprises injuries of every kind caused by mechanical vio- lence, such as bruises, contusions, fractures, luxa- tions, &c. fn which sense it is to be understood in the observations that follow. [It would appear, that the present rule in Eng- land is, that no injury constitutes a wound in law unless the continuity of the skin be broken; so that in a case where blows were inflicted with a hammer or iron instrument sufficient to break the collar-bone, and violently bruise but not break the skin, it was held not to be a wounding within the statute (Archbold.) A man was tried at the Central Criminal Court, in August, 1838, on a charge of cutting and wounding the prosecutor. The prisoner struck the prosecutor a severe blow on the temple with a heavy stone bottle, which was thereby broken to pieces. The prosecutor fell senseless, and it was a long time before he reco- vered. The medical witnesses underwent a rigid cross-examination by the prisoner's counsel, re- specting the meaning of the word " wound." They said that there had been a separation of the cuticle or outer skin of the temples, although there was no absolute wound in the usual acceptation of the word. They farther deposed that the prosecutor had lost the sight of his left eye, and the hearing of his left ear, and he was for a considerable time in a state of great danger, from which he had scarcely recovered. The prisoner's counsel main- tained that the injuries were not such as to con- stitute cutting and wounding in law. The court said, in order that a wound, in contemplation of law, should have been inflicted, it was neces- sary that the whole skin, and not the mere cuticle, should,have been separated and divided; and as the evidence did not show distinctly, that there was such a wound, those counts of the indictment could not be sustained. The prisoner was found guilty of an assault. (Taylor, A Manual of Me- dical Jurisprudence, p. 282: Lond. 1844.)] The chief points to be decided by the medical examiner in the case of a body found dead with wounds, are,— 1st, Were they inflicted during life] 2dly, were they the cause of death > and if so, were they the result of suicide or homicide } In order to settle these points, it will be necessary to consider the classification of wounds just al- luded to. They have been divided, for the pur- pose of medico-legal inquiry, into four classes,— 1st, those absolutely mortal; 2d, dangerous ; 3d, not mortal; 4th, accidentally mortal. This divi- sion of wounds is founded, as has been already stated, upon the usual terminations of such inju- ries, because it is well known that death some- times follows those of the slightest description ; and that others of the gravest kind terminate in recovery. Metzger (Page 327, and Beck, by Darwall, p. 324) mentions an instance of death from hemorrhage brought on by the slightest scratch of the thumb-nail. Dr. Paris (Paris and Fonblanque, Med. Jour. v. ii. p. 116) states he has seen a case in which the extraction of a tooth was followed by death in forty-eight hours ; and a similar case is reported by Mr. Blagden, (Med. Chir. Trans, vi. viii. p. 224.) An instance oc- curred lately to the writer of this article, in which a fatal hemorrhage followed a superficial incision made into the upper gum of an infant to liberate one of the incisor teeth. On inquiry, it appeared that another child of the same family had died of hemorrhage from some equally slight cause. Leech-bites have been known to produce death in children ; and in the case of Brain (Cro. Eliz. 778. Paris and Fonblanque, v. ii. p. 122) tried for the murder of Watts, it was proved that the deceased died instantly from a blow on the calf of his leg. On the other hand, we are not with- out instances of equally surprising recoveries from injuries of the severest kind. We have seen per- sons survive extensive fractures of the skull, in whom portions of the brain have protruded. Dr. Male mentions the case of a mendicant in Paris, from whose skull a portion of the bone was de- tached, large enough to be used by him to receive alms. The celebrated case of Mr. Tipple, (re- lated by Mr. W. Maiden. London, 1812,) whose thorax was transfixed by the shaft of a gig, is a striking illustration of the present sub- ject. Dr. Dunlop (Beck's Med. Jur. p. 332) re- cords a case of due1! in the West Indies, in which one gentleman hit another in the eye, the ball of which was completely obliterated ; and the leaden bullet, passing in through the orbit, came out in front of the external ear; nothwithstanding which destruction of the eye as well as injury of the brain, the officer recovered with the same facility as if he had only undergone the infliction of a flesh-wound. On account of these variations from the usual course, the consideration of injuries from wounds in a medico-legal point of view, is, on the conti- nent, and was formerly in these countries, a mat- ter of much more intricacy than it is at present. A person inflicting a wound on another was held amenable for the consequences during a year and a day ; a most inconvenient principle of respon- sibility, and one particularly calculated to create confusion, by either involving the innocent or suffering the guilty to escape. Chaussier relates a case illustrative of this point. Two men who had had some previous misunderstanding, encoun- tered each other on a public walk, when, after some altercation, one of them struck the other with a light cane and retreated; the other, enraged, 572 DEAD, (PERSONS FOUND) pursued him, but had not advanced many steps when he fell dead. On examination of the body, it was found that he had an aneurism of the aorta, which had burst from the excitement under which he laboured at the moment. Fortunately for the administration of justice in this kingdom, that act of the legislature called the " Ellenborough Act," relieves the medical witness of the present day from those serious embarrassments under which our predecessors must have laboured; as by it, wounding with an attempt to kill is deemed equally criminal whether death be the result or not. This, considering man as an accountable being, is the true and just view to take of thB crime. Still, however, the testimony of the me- dical witness will always be important, as by the nature of the injury, its seat, and direction, the evil intent is often to be inferred. Of mortal wounds those which cause instant death are wounds of the brain, of the heart, and large vessels connected with it, of the spinal mar- row on the neck, and blows on the stomach; these are all for the most part followed by imme- diate death. Wounds of the brain must be con- sidered as less fatal than those of the heart, in consequence of the recoveries which are some- times observed to take place after them, and even wounds of the heart are not necessarily immedi- ately fatal. The late Due de Berri lived for eight hours after being stabbed through the left ventri- cle, and similar cases are on record. Next in order as mortal wounds may be mentioned those which interfere with the function of respiration, such as extensive wounds of the diaphragm, and injuries which lay open both sides of the thorax in a considerable degree, and thus impede the dila- tation of the lungs. Among dangerous wounds must be ranked those of the pharynx and oesopha- gus, stomach and chylopoietic viscera, the danger of which will be of course in proportion to the extent of the injury. Also, wounds of the uri- nary bladder and of large blood-vessels in the head, thorax, and abdomen; severe contusions over any of these cavities ; wounds of the extre- mities implicating the great blood-vessels, or caus- ing compound fractures, or in tendinous situations from the danger of tetanus supervening. In the class of slight wounds are included those injuries by which the skin and muscles are bruised or divided, and where no tendon, aponeurosis, large nerve, or blood-vessel is touched, and the sys- tem has not received any severe shock ; to this class belong simple fractures and luxations. The last class, or wounds accidentally mortal, are influenced by different causes, which render this division an arbitrary one, and will be considered when we come to treat of those circumstances which alter the medico-legal character of wounds. In the article Pseudo-mohbid Appearances, [and in a previous part of this article,] allusion has been made to the spontaneous lividities which occur on the surface of dead bodies; the nature and causes of which, and the means of distin- guishing them from the effects of contusions in- flicted before death, are there pointed out. But there is another source of error connected with the examination of the surface, whieh it is neces- sary to dwell a little upon before we proceed to consider wounds of particular parts; that is, the possibility of appearances being caused by vio- lence offered to the body after death, which will resemble those that result from injuries received during life. That such a resemblance does occur is certain, if the blow be inflicted within a certain time after dissolution, and the power of discriminating be- tween the two is of the utmost moment to the medical jurist. We are indebted to Dr. Christi- son for the most accurate information we possess upon this subject, (Edin. Med. Surg. Journ. v. xxxi. p. 236.) His attention was forcibly drawn to it on the occasion of the trial of Burke and Hare at Edinburgh for- the murder of the woman Campbell for the purpose of selling her body. Before the confession of the accomplice, the whole weight of the case rested on the medi- cal evidence ; and one of the questions to be an- swered was, whether certain bruised marks and subcutaneous extravasations of blood, found on different parts of the body, were indications of injuries received before death. Being unable to find in authors on medical jurisprudence any in- formation precisely applicable to the case, except what rested on physiological speculation, Dr. Christison proceeded to subject the question to the extent of experiment. For this purpose, a large dog being strangled, and the hair on various parts of the head, trunk, and legs, being shaved, heavy blows were inflicted on these spots with a hammer, at intervals of from five minutes to two hours after death ; but at the end of twenty-four hours no trace of injury appeared in the seat of any of the blows. The next experiment was made on the body of a female an hour and three- quarters after death. Several heavy blows were inflicted with a stick across both shins, on the j fore-part of the thighs, on the breast, and on the side of the neck. In less than ten minutes, deep I bluish-black discolorations followed the blows on | the breast and neck. Twenty-five hours after death the blows were shown on the thighs, by faint stripes consisting of bluish-black points. On the breast and neck the stripes were as deep in tint as any contusions inflicted during life, but ' without swelling, the colour corresponding with | the prominent part of the stick. A severe blow had been struck over the crest of the ileum twenty- I three hours after death, which caused ruffling of the cuticle at the time, but no further appearance of injury. The third experiment was on the | body of a man. It was struck with a stick on I the left side of the back three hours and a quar- ter after death. More blows were struck on the right side seventeen hours after death. An ex- i amination was made forty-seven hours after death, I when the blows first struck were marked by two long narrow stripes of dark lividity, with an in- I tervening colourless stripe corresponding with the ! prominent part of the stick. The redness was I confined in this, as in the former case, to the mere surface of the true skin, the rest being natural. I The marks of the latter blows consisted of dry- ness and brownness of the surface, without effu- sion. The fourth was on the body of a young man, four hours after dissolution. It was struck with a stick, and on subsequent examination it was found that wherever the cuticle had been ! comminuted, the mark was dry and brown, but DEAD, (PERSONS FOUND) 573 there was no other discoloration of the skin. The i subject of the fifth experiment was a stout young ! man, on whose back several heavy blows were | struck with a mallet two hours after death. The body was inspected five hours afterwards, and pre- ] sented deep lividities in the seat of the blows, but | the substance of the skin was nowhere infiltrated or discoloured. The general conclusions to be drawn from the preceding facts are thus stated by Dr. Christison. " In respect to external contusions, the experi- ments show that for some hours after death blows will cause appearances, which, in point of colour, do not differ from the effects of blows inflicted recently before death; that the discoloration gene- rally arises, like lividity, from an effusion of the thinnest possible layer of the fluid part of the blood on the outer surface of the true skin ; but sometimes also from an effusion of thin blood into a perceptible stratum of the true skin itself; and that dark fluid blood may be even effused in the subcutaneous cellular tissue in the seat of the discolorations, so as to blacken or redden the membranous partitions of the adipose cells, but that this last effusion is never extensive. It can hardly be doubted that the appearances now de- scribed will exactly imitate slight contusions in- flicted during life; but I conceive that the blows in the latter case must be trivial." " When a blow inflicted during life is more se- vere, it may have the following effects, few or none of which, so far as we know, can originate in violence after death. 1. There may be swell- ing from the amount of the extravasation ; this is certainly never caused in the dead body. 2. When the violence has been applied a few days before death, there will be a yellow margin round the black mark, which is another appearance that cannot be formed except during life. 3. There may be clots of blood in the subjacent cellular tis- sue, either with or without swelling : these ap- pearances I have never seen accompanying con- tusions caused in the dead body; but it may be doubted whether clots might not be formed if the injury was inflicted very soon after death, and had the effect of lacerating a considerable vessel in the neighbourhood of loose cellular tissue. 4. In the instances in which the blood does not coagulate at all after death, contusions caused during life may be recognised by the extent of the effusion into the cellular tissue. In a part not liable to be infiltrated by its depending position, and not in the vicinity of a large vein, a deep effusion of fluid blood, which fills and distends the cells of the cellular tissue can hardly be produced on the dead body. 5. Perhaps one of the most charac- teristic 6igns of a contusion inflicted during life is, incorporation of blood with the whole thick- ness of the true skin, rendering it black instead of white, and increasing its firmness and resist- ance. This sign may not be always present, for, as every one knows, a blow may cause extensive extravasation below the skin, without affecting the skin itself. But when present, I am disposed to consider it characteristic, because I have never been able to produce it in the dead body, and it is not easy to conceive how such a change can be wrought in so dense a texture as the skin, with- out the force and agency of living vessels." " It is impossible to fix absolutely the limit of the interval beyond which contusions cannot be imitated by violence applied to the dead body. It appears to vary with the state of the blood, and the time which elapses before the body cools, and the joints stiffen. Sometimes the appearance of contusions can hardly be produced two hours after death (Experiment 5th) ; sometimes they may be slightly caused three hours and a quarter after it (Exp. 3rd) ; but I should be inclined to think this period very near the extreme limit. Wherever the warmth of the body and laxity of the muscles were not considerable at the time the injury was inflicted, we may be sure the appear- ance of contusions cannot be considerable (Exp. 2d). It is probably, therefore, only on the trunk that even in the most favourable state of the body, namely, when the blood remains altogether fluid, any material mark of contusion can be produced so late as two hours after death." With respect to wounds of the head, it is well known that all kinds of violence are more dan- gerous in some constitutions than in others. In good constitutions, wounds may not be danger- ous, which in old, bilious, or scrofulous habits, are often attended by death, chiefly in consequence of the erysipelatous inflammation that succeeds them. Fracture of the bones of the cranium may take place without any correspondent injury of the integuments, and the symptoms in such cases are extremely equivocal and deceitful. A mere simple fracture when no more is implied than solution of continuity confined to the bony substance without displacement or injury to the neighbouring parts, is not necessarily an event of great importance. In so simple an occurrence we can hardly suppose bad consequences to arise. Simple cases like these, however, are very rare, and these injuries are almost always complicated with some affection more or less severe of the in- ternal parts. Although fractures may be consid- ered more dangerous when accompanied with depression, yet we cannot ascertain the precise degree of injury sustained by the contents of the cranium from the external wound, nor does it fol- low that the more extensive it is, the more certain is the danger. In fact, our knowledge of the economy of the brain is very limited, and though injuries of it are generally of a most serious char- acter, yet we find surprising recoveries take place. The effusion of a small quantity of blood or pus upon its surface may, and often does, cause the most alarming symptoms, and terminate in death; while, on the other hand, large portions of the brain itself have been removed, and foreign bo- dies, as a musket-ball, and portions of the skull have been lodged in it, and recovery has taken place. It is hence exceedingly difficult to define the exact amount of injury to the head necessary to cause death ; nevertheless, in case of a body found dead with fracture of the skull, and where no other sufficient cause of death can be ascer- tained, we are justified in attributing the event to the injury. We come to this conclusion from our knowledge of another effect of violence offer- ed to the head, and which must always accompa- ny the former in a greater or less degree,—name- ly, concussion or commotion of the brain. By concussion of the brain is meant a violent and 574 DEAD, (PERSONS FOUND) sudden shake of the organ without any apparent wound or mark of injury being left. It may be caused by violence offered directly to the head, or transmitted to it by falls on the feet or nates. A remarkable instance of the former is given in the Transactions of the Royal Academy of Paris. A stout young criminal was condemned to be broken on the wheel, and wishing to escape the execution, ran head foremost against the wall of his dungeon, and instantly fell dead. On open- ing the head, not the slightest appearance of in- jury was discoverable in either skull, brain, or spinal marrow, except a very minute separation in the squamous suture of one side. Certain injuries done to the face belong to this division of wounds. When these are confined to the face alone, the most serious consequence may be no more than deformity; but mortal wounds have been inflicted through the face on the con- tents of the cranium. The most common of these is where a sharp-pointed instrument is struck into the eye, and pierces the orbital plate of the frontal bone. The celebrated comedian Charles Macklin was tried in the year 1753 for the murder of a brother-player, whom he struck accidentally in the eye with a cane, in some altercation that took place in the green-room. (State Trials.) Tho- mas Hallum, the sufferer, died the next day, and it was found ffiat the point of the cane had passed through the orbital plate, and wounded the brain. A case occurred some years ago in Dublin of a similar nature. A gentleman received a thrust of a watchman's pike in the eye, in some drunken broil in the street : the immediate effects were so trifling, and the external wound so slight, that he took no notice of it until he was attacked with in- flammation of the brain, which killed him in a few days. Mr. Colles, under whose care he was, opened the head, and found a small round hole in the orbital plate of the frontal bone, in the neigh- bourhood of which there was a large collection of pus. The part is preserved in the museum of the College of Surgeons of Dublin. In like man- ner, blows upon the nose have not only crushed that organ, but also driven the ethmoid bone up into the brain; and sharp-pointed instruments have sometimes penetrated the brain through this organ, and proved fatal. Such instances as these show how necessary it is to investigate with the greatest accuracy all cases of sudden death; for without the greatest care and attention, cases of this description must elude discovery. We make this observation in order to induce medical ex- aminers to bestow more pains on the highly im- portant trust they undertake, for it must be con- fessed that in investigations of this sort, we fall far short of the diligence of our Continental brethren. As connected with wounds of the head, we may observe that children, either before or after birth, may be, and have been, destroyed by fine sharp- pointed instruments passed through one of the i fontanelles. A Parisian midwife was executed some years ago on its being discovered that she was in the habit of procuring still-born children for those who desired it, by piercing the brain of the infant before its birth with a fine wire. A I wound of this description leaves very little mark, I and would of course escape superficial observation, i The neck comprises many important parts, a wound of which is necessarily followed by death. Wounds of the integuments and muscles of the neck may be considered simple wounds, although they are sometimes difficult to heal in conse- quence of the mobility of the parts ; but wounds of the carotid arteries, jugular veins, and spinal marrow, are for the most part immediately fatal. Lacerated wounds of the carotid artery, however, may not be quickly followed by death, an instance of which came within our knowledge some years ago. The artery was torn by the horn of a cow, and the bleeding from the wound, although con- siderable, was not sufficient to destroy the patient, who survived long enough to have the artery tied, and subsequently recovered. It has been said that a complete division of the trachea is mortal; but the danger attending a wound of this sort arises from the injury usually inflicted upon the great vessels and nerves in its neighbourhood at the same time, more than from the wound of the air- tube itself, for we know that mere division of this part is not necessarily fatal, although it may be very difficult to heal from the great mobility of the part, and the constant passage of the air through it. Wounds of the pharynx and ceso- phagus are much to be dreaded, as well on ac- count of the other important parts which must be wounded along with them, as from the circum- stance that through this channel the nourishment of the body is conveyed, and that the act of deglu- tition is directly opposed to a speedy adhesion of the parts. The following case gives a good pic- ture of the dangers and difficulties attending wounds of these parts. (Edin. Med. Surg. Jour. v. xvi. p. 353.) A few years ago a prisoner in Edinburgh jail cut his throat transversely, divid- ing the larynx quite across at the upper end of the cricoid cartilage, and the separated extremities receded from each other to the distance of three inches ; the great vessels and nerves escaped in- jury from the cut being so high. The professional gentlemen who saw him were satisfied that the oesophagus was also cut entirely across. Several attempts must have been made, as another open- ing was afterwards discovered in the windpipe. In this state a junction of the parts was found to be impracticable, and the ligatures that had been applied with the view of making the best possible approach were separated by his incessant exer- tions in passing water through the mouth, and out at the wound, in which way he used several buckets full in the course of one day. He was supported in the first instance by nutritious ene- mata, and afterwards by means of a tube conveyed through the wound into the oesophagus and sto- mach. After much trouble to the practitioners, and considerable risk to the patient, the functions of breathing and ingestion were carried on through a tube in each passage introduced by the wound, the tracheal tube being removed when it was ne- cessary to apply the other. The man was after- wards tried, acquitted, and liberated from jail, and continued to live under the disadvantages men- tioned. Besides the parts just alluded to, the neck gives pissage to the par vagum and the great sympathetic nerve, injuries of which, even partial or at but one side, must be considered of the most dangerous kinds, as from them princl- DEAD, (PERSONS FOUND) 575 pally the cardiac and pulmonary plexuses are formed. Injuries to the spinal marrow, either by fracture or dislocation of the vertebra, or by a wound penetrating between two of the vertebra, are absolutely fatal. Fracture or dislocation is generally the result of accident, as a fall, or what coachmen are liable to—striking the head against a low arch-way in driving under it. They also sometimes, though rarely, occur in hanging. But they may happen in consequence of disease; a striking example of which came under the ob- servation of the writer some years ago. A boy, who was under treatment in the Richmond Hos- pital (Dublin) for some disease of the leg, was one morning, during the visit, sitting up in his bed talking to those around him, when his head suddenly fell forward on the breast, and he drop- ped dead. On examination, it was found that the root of the odontoid process of the second vertebra, and the transverse ligament that binds it in its situation, was ulcerated, and in the mo- tion of the head it had broken off, and compress- ing the spinal cord, had produced instantaneous death. A consideration of the important organs con- tained in the thorax will lead us to estimate the danger arising from wounds which penetrate suf- ficiently deep to reach them. Wounds of the lungs we know are not necessarily fatal, though for the most part they are exceedingly dangerous, from the size and number of the blood-vessels by which they are traversed. These organs are sometimes seriously injured although no external wound be present. This arises from the fractured portion of a broken rib being driven into their substance, of which injury hemorrhage, emphyse- ma, and inflammation, are the consequences most to be dreaded. Nevertheless, although injuries of these organs are of a very serious nature, and not unfrequently terminate fatally, we find occa- sionally that they support most extensive injury. This is familiar to many military and naval sur- geons who during the late war had opportunity of observing the powers of nature in repairing extensive injuries of these organs ; and we before alluded to the case of a gentleman who recovered after having both sides of his thorax transfixed by the shaft of a gig. It is quite true that penetrat- ing wounds of the heart are, generally speaking, mortal; but there are so many cases on record of individuals who survived, some of them for days, others entirely, after wounds of this organ, that we cannot agree with those authors who maintain that such injuries are necessarily and instantly mortal. At the battle of Corunna a soldier re- ceived a shot in the chest and fell insensible. He was found by a comrade with signs of life, who carried him off the field, and he was immediately embarked with the troops and brought to Ply- mouth, where he died fourteen days after the re- ceipt of the wound. Mr. Fuge, who records the case, (Edin. Med. Surg. Jour. v. xiv. p. 129,) states that, on examining the body, two quarts of blood were found in the left side of the thorax, the lunjr of that side being compressed towards the s],ine. A transverse opening an inch long was observed in the right ventricle of the heart near the origin of the pulmonary artery, and the ball was lying in the pericardium. To the same paper is ap- pended an account of a suicide who lived forty- four hours after discharging a pistol into his breast, and in whom the right ventricle was found wounded, and the ball in the pericardium. Du- puytren, in his " Lecons Orales," expresses his opinion that wounds of the heart are oftener cured than is generally imagined. He founds his belief on the instances of animals killed in the chase, in whom balls and the cicatrices of former wounds have been found, and also on similar instances in the human subject. Many individuals have pre- sented all the symptoms of wound of the heart, and yet recovered ; and he alludes particularly to the case of a soldier, in whom, six years after the healing of a wound of the chest, a musket-ball was found in the right ventricle of the heart, near its apex. From these circumstances we think we are justified in stating that wounds of all parts of the heart, provided they are narrow, are not ne- cessarily immediately fatal. Acupuncture of this organ has been practised at Warsaw with im- punity. If, however, the wound be considerable, some lines for example, death is usually instan- taneous, from the great deluge of blood that is poured into the pericardium and chest. Under a wound of less dimensions the individual may survive for some days. Thus, in one of the cases mentioned by Dupuytren, a man thirty-four years of age received two stabs of a knife, one in the belly, the other in the chest, of six and seven lines in length. He lived for eight days, and then died with symptoms of diseased brain, having been af- fected with tetanic convulsions for two days before his death. The stomach was found perforated, and there were four ounces of blood in the left side of the chest, which had come from one of the intercostal arteries opened by the wounding in- strument. In the pericardium was observed a per- foration three lines and a half long, and a wound of the same extent in the middle of the left ven- tricle. In another individual, who died mad, after attempting suicide by amputating the penis, several small wounds of the heart were found, which must have been inflicted several days be- fore with a small round instrument found in his possession. Another man, aged forty years, lived seventy-two hours with three wounds penetrating the left ventricle, inflicted by himself with a sharpened file. In the thesis of M. Sanson nu- merous instances are mentioned of persons surviv- ing wounds of both ventricles, some of them for twenty days. The late Due de Berri, whose in- stance has already been alluded to, lived for eight hours, although stabbed through and through the left ventricle with a long round instrument used by saddlers in piercing leather. All these in- stances go to prove that wounds of this organ are not necessarily instantaneously fatal,—a very im- portant fact in legal medicine, for it sanctions the possibility of an individual removing to a con- siderable distance after the receipt of a mortal wound, and being found dead some hours or days after. As an illustration of this fact, involving a question of life or death, we may adduce the fol- lowing case mentioned by Dr. Dunlop, (Beck, by Darwall, p. 335.) as having been tried in Glasgow in the year 1819. The keeper of a house of bad fame in Greenock, was indicted for the murder of a sailor by shooting 576 DEAD, (PERSONS FOUND) him through the chest It appeared from the evi- dence of the medical witnesses, that the auricles and part of the aorta next the heart were shattered to atoms by the slugs and brass nails with which the piece was charged, and in their opinion he must have dropped down dead the moment he received the shot; therefore, as the body was found in the street, and the door of the house was eighteen feet up an entry, it followed that the prisoner must have run after him into the street, and there shot him. For the prisoner, it was urged and proved that he had shot him through the door of his own house, which he was attempt- ing to enter by force. And besides direct testi- mony to this effect from those within the house, and from a lad who was along with the deceased at the time, it came out in evidence that there was a stream of blood from the door of the house to the spot where the body was found, which could not have run from the body towards the house, as the threshold of the door was on a higher level than the pavement of the street. On this evidence the prisoner was acquitted. In judging of wounds of this organ, the size and shape of the instru- ment, and the depth and direction of the wound, are to be considered. The extent of the wound, as we have already stated, makes a great differ- ence in the chance of recovery. But there is one circumstance which is not very easily explained, that is, how so large a wound as a musket-ball must make, permits life to be carried on for an instant. It is generally admitted that wounds of the aorta and vena cava are mortal; but this must be taken with limitation, for very small punctured wounds may certainly be inflicted without involving the life of the individual. What the extent of a wound necessary to cause death is, we cannot precisely say; but we can conceive the possibility of these vessels being pierced with an acupuncture needle with impunity. The thoracic duct, from the important function it performs, can scarcely be wounded without inducing fatal consequences. This arises as well from the extravasation of its contents into the thorax, as from the interruption to the supply of nutriment to the body. Wounds of the diaphragm have been generally divided into those of its ten- dinous and of its muscular portions; but the dis- tinction is useless, for it is not ascertained that injuries of one portion are less serious than those of the other; and it is certain that both are highly dangerous. There is a source of danger con- nected with wounds of this muscle, which it is well to bear in mind, and that is, the possibility of some of the abdominal viscera being pushed through the opening, and there being strangulated. Dr. Gordon Smith (Principles of Forensic Medi- cine, p. 279) relates a case of this sort. A sharp- pointd weapon had passed through the diaphragm, notwithstanding which the patient made a rapid and perfect recovery to all appearance. At the end of about three months, he died from strangu- lated hernia of the stomach, which had passed through the wound of the diaphragm into the thorax. Wounds of the abdomen, however slight, pro- vided they penetrate its cavity, must be considered dangerous, from the great tendency of its lining membrane to take on inflammatory action, and the rapidity with which inflammation runs over its surface when once established. Penetrating wounds may also strike one or more of the viscera contained in the abdomen, in which case the danger arises both from the lesion of the organ itself involving derangement of structure and function, and from the effusion of its contents into the abdominal cavity. Wounds of the stomach are to be deemed highly dangerous, although there has been great diversity of opinion concerning their mortality. Dr. Beck takes notice of the declared opinions of some of the German colleges upon this point. A wound of the stomach was declared only acci- dentally mortal by the faculty of Giessen, and absolutely mortal by the college at Frankfort; while, in another case, a wound was considered mortal by the faculty at Leipsic, and not so by that of Helmstadt and Wirtemburg. The fact is, that very extraordinary escapes have followed wounds of this viscus. The writer recollects the "^ case of a pauper in the house of industry in Dub- lin, about the year 1814, who had received a wound of the stomach some years previously, from which he recovered, with a fistulous opening in the side, of considerable size, communicating with the stomach. He kept this plugged with a tent of lint or tow, and, to gratify visitors, he would, for the reward of a few pence, take a large drink of milk or other fluid, and withdrawing the plug, suffer it to flow out through the external opening. This and similar instances tend to show that wounds of the stomach inflicted from without, although highly dangerous, are not absolutely mortal. But we can scarcely say the same of rupture of the stomach caused by a blow or con- tusion on the part, inasmuch as the contents have then no chance of an external outlet, and must be poured into the peritoneal cavity. While upon this subject, we may remark that rupture of the stomach may take place without external violence, and it then commonly causes death after a train of symptoms that closely resemble the effects of the irritant poisons. This accident usually occurs from the efforts to discharge, by vomiting, the contents of an over-filled stomach. When the organ is in this condition, it is carried forward, and makes an abrupt turn on the lower end of the oesophagus, which acts as a valve, and opposes the exit of the contained matters. A striking case of this kind is related by Dr. Lallemand. (Inaug. Dis. Paris, 1818. Christison on Poisons, first edition, p. 88.) A woman convalescent from a long attack of dyspepsia, being desirous to make amends for her long privations as to diet, ate one day to satiety. Ere long she was seized with a sense of weight in the stomach, nausea, and fruitless efforts to vomit. Then she all at once uttered a piercing shriek, and exclaimed that she felt her stomach tearing open; afterwards she ceased to make efforts to vomit, soon became insensible, and in the course of the night she expired. In the fore part of the stomach there was a laceration five inches long, and a great deal of half-digested food had escaped into the cavity of the abdomen. Professor Barzelotti (Medicina legale, ii. p. 22) notices a case in which the rup- ture was caused, not by the accumulation of food, but by the accumulation of gases arising from DEAD, (PERSONS FOUND) 577 depraved digestion, similar to what arises in cows which have eaten largely of clover. In these cases the train of symptoms would lead one to suspect the administration of an irritant poison, but sometimes death is instantaneous. Dr. Chris- tison (loc. cit.) mentions the case of a coal- heaver in London, who, while attempting to raise a heavy weight, suddenly cried out, clapped his hands over his stomach, drew two deep sighs, and died on the spot. On dissection, a lacerated hole was found in the stomach, big enough to admit the thumb, and the stomach did not contain any food. These cases show the great danger arising from simple rupture of the stomach; but the danger is still more increased when the laceration is effected by external violence; for then, besides the injury done to the organ itself, the solar plexus and semi-lunar ganglion are implicated in its effects. These parts are so essential to life, that injuries to them are sometimes followed by the most rapid and perfect death, the entire vital power appearing to be at once extinguished. Persons suffering laceration of the intestines from blows or contusions are likewise «xposed to the greatest danger; but perforated wounds do not appear of the same mortal character; and when proper treatment is pursued, very surprising recoveries have taken place. Wounds of the small intestines are said to be more dangerous than those of the larger, in consequence of the more important functions they perform, and of their being supplied with a greater number of nerves ; but we cannot perceive the value of this distinction, as the principal dangers, extravasation and inflammation, are not influenced by either of these circumstances. Individuals may be killed by wounds of the liver; although small superficial wounds, if the sufferer escapes inflammation, may not be attended by serious consequences; but more extensive and deeper injuries may cause a fatal hemorrhage, by opening some of the numerous and large blood- vessels by which that viscus is traversed. Lace- ration of the liver by falls is not an uncommon occurrence; and when it happens, it most com- monly causes the death of the patient. Besides the injury to the liver itself, its great reservoir, the gall-bladder, is exposed to perforation and rupture; and this is an accident of the most fatal character, from the effusion of bile into the peritoneum. This secretion and the urine are the most irritating of all the fluids of the body, and never fail to cause death when suffered to escape into the belly. Wounds of the urinary bladder, therefore, except at the part uncovered by the peritoneum, are of the most fatal kind. Before we leave this part of our subject, we wish to make some remarks upon a form of acci- dent which has been long known and described, but about which very vague and unphilosophical notions were entertained; — we allude to what have been termed wind-contusions. It is not rare to find upon a field of battle dead bodies preserving their form and the integrity of their surface, and not presenting externally any lesion by which death can be accounted for ; but if the body be opened, some of the viscera of the thorax or abdomen are found bruised and ruptured, and an extravasation of black fluid blood or of the con- Vot. I___73 21 tents of the stomach and intestines. When the nature and extent of these internal lesions are considered, it is evident that death must have been instantaneous, and the vital powers so quickly and completely destroyed, that there has not been time sufficient to allow of the infiltration of blood into the cutaneous tissue, so as to produce ecchymosis. As this kind of injury has been observed particu- larly after battles, it was imagined that death was caused by the wind of cannon-balls, that is, by the compression of the air caused by the passage of the shot in the vicinity of the individual. But when we consider the fluidity and elasticity of the atmosphere, and the little resistance it makes to the passage of bodies through it, we must perceive that this explanation is untenable; for the uncon- fined air never can be compressed to such a point as to become a mass capable of contusing or even giving a severe shock to our bodies. It is now generally believed that these lesions are caused by the contact of the cannon-shot itself, when towards the close of its trajet. For the first moment of projection, when the force is greatest, it pierces, tears, and carries off all that occurs in the line of its direction ; but when it approaches the end of its course, and its velocity is considera- bly diminished, it loses the power of producing these effects, and as the skin is supple and exten- sible, and the parietes of the thorax and abdomen are flexible and elastic, and protected by clothing, they yield to the impetus without tearing, and resume their original form as soon as the com- pressing force ceases to act. But the parts which lie deeper than the parietes, and whose tissue is less flexible, and supported by bone, experience necessarily the whole force of the compression, and are thus contused, bruised, or, in some in- stances, reduced to a complete pulp. Any doubt of the validity of this explanation is removed by a reference to reports of cases of injuries not depen- dent on fire-arms, in which the same laceration and contusion of the viscera of the abdomen and thorax have been found without any appearance of external injury. Chaussier relates the case Of a strong man, thirty years of age, who, while driving a cart heavily laden with stones, attempted to get on the back of one of the horses, and falling in the endeavour, the wheel passed slowly over his left shoulder, crossing the clavicle near the sternum, and continuing its course obliquely over the entire left side of the thorax. The body was found the following morning on the road, lying on the back with the track of the wheel marked on the clothes by a broad streak of mud. Never- theless, on stripping the body, there was no ap- pearance on its exterior that could lead to a knowledge of the cause of death. However, after removing the integuments and muscles of the thorax, it was found that the clavicle was torn from the sternum, and all the ribs of the left side were fractured, but there was no ecchymosis under the skin or round the fractures. The first rib was broken in one place near the sternum, but all the rest in two, about three inches apart, which cor- responded with the breadth of the wheel. These fractures were not complete, but were limited to the inner surface. On opening the thorax, the pericardium was found distended with coagulated blood, and a large rent was discovered in the left 578 DEAD, (PERSONS FOUND) auricle of the heart. From this it is evident that pressure by the passage of a heavy body may cause bruising or rupture of the internal parts, without leaving any appearance of its action on the exterior; and in like manner those great con- tusions and sudden d£aths, without external mark of violence, observed after actions, are to be as- cribed to the size and weight of cannon-shot strik- ing the body with diminished velocity. We do not deem it necessary to dwell upon wounds of the extremities, as the danger of speedy death in these cases depends upon the escape of blood from some of the great blood-vessels im- plicated in the injury, a complication which is easily detected by dissection. But there is a form of injury connected with this part of our subject on which it is necessary to make a few observa- tions. We allude to wounds of the external parts of generation in the female, which may prove fatal by excessive hemorrhage ; the peculiar structure of the parts, consisting of erectile tissue, which is very vascular, giving rise to a continued, steady, though not very rapid flow of blood. In illustra- tion of this point we may refer to two cases re- lated by Mr. Watson. The first is that of a woman who resided near Edinburgh, whose hus- band was tried and convicted of having murdered her in the year 1826. " The body," says Mr. Watson, " of this unfortunate person was inspect- ed by Mr. Newbigging and myself. We were in- formed of her having died suddenly. She seemed to be about fifty years of age, of stout form, of very low rank, having lived in a small, dirty, ill- furnished house, having only some shavings and straw upon the floor, covered with a rug for a bed. The clothes in contact with the private parts were stained with blood. No appearance of injury could be perceived on any part of the body exter- nally ; but upon separating the labia pudendi, a wound about an inch and a quarter in length was observed upon the inner side of the right nympha. This wound was evidently recent, its surface being covered with coagulated blood. Externally it con- sisted of a remarkably clean, straight incision pa- rallel with the nympha. Internally the finger could be introduced in four different directions to the depth of about two and a quarter inches in each: upwards and backwards towards the divi- sion of the iliac artery ; backwards towards the tuberosity of the ischium; laterally towards the hip-joint; and upwards towards the mons veneris. In each direction the wound was of nearly the same diameter, which readily admitted the finger, and had distinctly an obtuse termination. By in- jecting warm water into the large vessels, we found that none of them had been wounded, and the penetrating instrument seemed to have been forced only through the cellular tissue. The wea- pon had passed up to the peritoneum at the right side of the pelvis, under which there was a con- siderable effusion of blood, but had not penetrated it. Another very small, but also very clean ex- ternal incision was observed at the side of that above described. The cavities of the cranium, thorax, and abdomen, were each examined, and their contents found to be quite healthy and natu- ral. The hemorrhage, therefore, which had taken place from the wound was the only cause which we could assign for her death, and this we knew from the nature and structure (erectile spongy tissue) of the parts cut, must have been profuse." It was proved on the trial that the wound was in- flicted by a razor. The second case is very similar to that first de- scribed : it occurred in the person of a woman who lived in Edinburgh, and whose sudden death was occasioned by a wound received on the morn- ing of the 1st of January, 1831. This case was examined by Mr. Mitchelhill and Mr. Watson. They found the body dressed in the ordinary day- clothes, which they removed carefully, and ob- served no wound or tear on them, but the lower parts were drenched with blood. They then dis- covered that the hemorrhage had proceeded from a wound of the left labium pudendi, consisting of a very clean incision about three quarters of an inch in length, parallel with the margin of the labium. When the finger was introduced into this wound, it entered a bloody cavity sufficient to have contained a small hen's egg, and from this cavity the finger could be passed upwards towards the symphisis pubis, downwards towards the peri- neum, and backwards by the side of the vagina and rectum. Its greatest depth at any of these places was between two and three inches. When the internal part of the wound was laid open, the divided orifices of several pretty large arteries and veins were seen, and particularly the divided ex- tremities of the large artery going to the clitoris. By the evidence adduced at the trial of two young men, brothers, for the murder of this woman, it was obvious she had received a wound at the first floor of a common stair, almost immediately after which she was precipitated headlong to the bottom of the stair. In reference to these cases Mr. Wat- son remarks, « In both, this part of the body seems to have been selected by the murderers to effect their design secretly ; for in both, but particularly in the first, the wound was concealed to a super- ficial observer ; and they may have had an idea, from the frequency of flooding in females, that their death might have been supposed to have happened either from this cause or by accidentally injuring themselves by sitting down upon some sharp body. For it is a curious fact that in both cases the probable murderers were the first to go for medical aid to the deceased. Circumstunces affecting the medico-legal cha- racter of wounds.— So far we have considered wounds according to the consequences that usu- ally attend them; but the medical jurist should ever bear in mind the fact, that injuries, naturally belonging to the class of slight wounds, may ac- quire the character of severe, dangerous, or mor- tal, from the co-operation of circumstances more or less extraneous, and, therefore, relieving the in- flictor more or less from responsibility. We have already alluded to the memorable aphorism of .Mr. Hobbs, that there never was a wound but it might prove mortal. Let us now inquire into those cir- cumstances that are thus capable of altering the medico-legal character of wounds : these are age, sex, constitutional peculiarities, previous injury or disease, subsequent injury or disease ; malum regimen. Of age, it may be said that adult age is on the whole the most favourable to recovery from inju- ries : of this we have a very striking example in DEAD, (PERSONS FOUND) 579 the case of burns, the effects of which are much more severely felt by young subjects, and the mor- tality attending them is greater in this class than in persons who have reached adult age. Frac- tures may, perhaps, form an exception to this, as it is observed that this species of injury is less fatal in children. Sex is a circumstance of aggravation in the case of blows on the breast of a female. This organ being in early life endowed with peculiar sensibi- lity, and in later years being prone to take on cancerous action when excited by injury, is natu- rally a very vulnerable part, and a comparatively trifling blow in this situation, may be followed by the severest effects. In like manner, an injury on the abdomen of a pregnant woman must be regarded as a more dangerous accident than the same force applied under different circumstances. .Constitutionalpeculiarities do not form a good exculpatory plea unless the wound be slight. They are of two kinds, constitutional infirmities and malformation. Slight wounds may be ren- dered dangerous, and even mortal, from an ex- treme irritability of the nervous system. We see this in the different effects produced on different patients by surgical operations, some bearing with fortitude what others unaccountably sink under. The scrofulous diathesis and venereal taint influ- ence the result of wounds, and diseases of the bones and joints have succeeded in such constitu- tions to injuries which would have been of little consequence in sound ones. The hemorrheal diathesis is one calculated to increase the danger of slight wounds in a remarkable manner, some striking examples of which have been already mentioned. Original or accidental malformation may likewise contribute to the fatal effects of a slight injury. Thus transposition of the viscera may bring an organ within reach of a wound that might have been otherwise harmless. A very re- markable instance of such malformation is pre- served in the museum of the Dublin College of Surgeons. The subject was a woman advanced in life, who died in one of the hospitals of the House of Industry, and who had never given any indication during life of her peculiar formation. On examination of the body after death, all the viscera of the thorax and abdomen were found transposed. The heart was at the right side, the liver at the left, the stomach and spleen at the right, the coecum in the left iliac fossa, and the sigmoid flexure of the colon in the right, and all the blood-vessels were transposed to correspond. But besides such a general transposition, there may be a partial malposition. Thus, an artery, usually deeply-seated may take a superficial course, and prove a source of danger in case of a slight wound inflicted in that situation. A case in which death occurred in consequence of malposition of an artery, happened in the hands of one of the most experienced surgeons in Dublin some years ago. A fish-bone stuck in the throat of an indi- vidual, who applied to the gentleman alluded to for relief. A probang was passed down the oeso- phagus, when suddenly an immense gush of blood took place from the mouth of the patient, and he dropped dead in his hands. On examining the body to ascertain the cause of this unexpected fatality, it was found that the arteria innominata, instead of following its usual course in front of the trachea, had dipped down between it and the oesophagus, just at the spot where the fish-bone had lodged, the point of which had been forced by the probang through the oesophagus into the artery, and thus caused the death of the patient. I Besides these congenital malformations, there may be accidental displacement of a viscus, as in her- nia, by which a blow in certain situations will be made more dangerous. Previous injury or disease is a plea sometimes set up in extenuation of guilt, but it is a feeble one, and in fact untenable if the injury is of a usually dangerous character, or has manifestly accelerated the death of the individual. It may, however, be used with advantage if the injury was slight; but the degree of weight that should be allowed to it in law is sometimes very difficult of decision. The chief questions on the subject are, 1st, Was the new injury adequate to cause serious mischief in ordinary cases ? 2d, Whether did the injury, or the previous disease or accident, occasion death ? 3d, Did the alleged previous harm really exist, or was it the consequence of the injury ? Chaussier relates the case of a boy who was killed by a very gentle stroke of a switch upon the head, which in ordinary cases would have caused no mischief, but proved fatal in this in consequence of previous absorption of the skull at the particular part struck. An interesting illus- tration of the second question has already been quoted from the same author, in which death was produced by the bursting of an internal aneurism. Cases that come under our third head are very common; we will content ourselves by quoting one by Dr. Klapp of Philadelphia. (American Medical Recorder, v. i. p. 156, and Beck, by Dar- wall, p. 352.) An individual in that city, who was in habits of intemperance, engaged in a brawl, received an injury, and died thirty-eight hours after the affray. He walked and spoke after receiving the injury, and even drank part of a pint of spirits, but was shortly seized with insen- sibility, dilated pupils, oppressed breathing, and died without any return of sense. The bone and the brain beneath the injured part were examined and found natural. The mucous membrane of the cardia and the upper part of the stomach were greatly inflamed ; the other parts were not dis- eased. Before the court, Drs. Hartshorn and Klapp gave it as their opinion that the injury to the head had not been the cause of death, and that there was no appearance of a blow on or near the region of the stomach. A verdict of acquittal was the result. But supposing the injury to be of such a kind as would alone prove fatal, then the second question arises, Whether did the injury or the previous disease cause death ? There are circumstances which may render this a nice question to answer : thus, for instance, the disease and the injury may cause the same symptoms and appearances, as in the case of apoplexy and extra- vasation of blood from a blow. In cases of this kind confusion and difficulty are sure to occur, when the investigation is made according to the Continental system; but in these countries the animus with which the injury was inflicted being 580 DEAD, (PERSONS FOUND) the chief object sought after, the medical witness is saved from the nice 'distinctions laid down in foreign authors. Subsequent injury or disease may also alter the medico-legal character of injuries. It may happen that a disease totally unconnected with the effects of an injury, may invade a person who has received a wound, and carry him off. This is a case that sometimes creates great difficulty. Thus, a typhous fever may attack an individual labouring under a wound of the head, or sponta- neous pleurisy may occur after injury to the chest; in both of which cases it is evident that great ob- scurity must exist. We recollect the case of a boy who was admitted into the Richmond Hospital, Dublin, labouring under a wound of the head with a small depressed fracture of the right parietal bone. He went on well for some days, when headach came on, flushed countenance, fast and hard pulse, dry and burning skin, and thirst with sickness of stomach. It was at once supposed that inflammation of the brain had set in, and preparations were making for trephining him, when attention was accidentally turned to his right arm, from which he had been bled on the day of his admission, and in it, in the neighbour- hood of the puncture and spreading up the arm under the fascia, a large collection of matter was discovered, on the liberation of which, all the bad symptoms gradually disappeared, and the boy recovered well without any operation. This was a case in which a subsequent disease put on the appearance of the worst consequences of the in- jury, and was at first mistaken for them. Zacchias relates an instance illustrative of the difficulty that may occur in these cases. During a period in which the plague raged at Rome, a man received a wound on the head, which de- nuded the bone, but left no fracture. The wound appeared favourable for the first three days; but at the termination of that period a fever came on, accompanied with bilious vomiting and violent inflammation of the wounded part. On the fourth day the wound was gangrenous, petechias and buboes occurred, and he died on the sixth. It appeared afterwards that he had been visited during the first two days of his illness by a friend, who had died of the plague on the fourth day after communicating the disease to the wounded person. Tetanus is a consequence of wounds which must occur to every one as likely to alter their medico-legal character. A case occurred a few years ago in England, in which the super- vention of this disease upon a slight injury had a great influence upon the fate of a prisoner. A gentleman fired a gun, loaded with small shot, at a boy whom he found trespassing on his ground. He wounded him slightly in the leg, and the boy appeared going on well until he was attacked with tetanus, of which disease he died. The gentleman was tried, found guilty of murder, and executed. This case forms a good example of what has just been stated respecting the English practice in such cases; for if the wound had been inflicted with a stick or whip, or other implement, it is almost certain that a verdict of murder would not have been returned against the prisoner; but a gun having been used, made it appear that the intent was to do some grievous bodily harm, and the heaviest penalty of the law was accordingly inflicted. Malum regimen, or improper treatment, often constitutes a very strong exculpatory plea, as by it the character of wounds may be materially altered for the worse. Accidental or inevitable want of skilful attendance is not a valid plea; but if the omission was intentional or avoidable, it takes off the responsibility of the inflictor in a great degree. If a patient should refuse to sub- mit to proper treatment, or should persevere in the use of forbidden articles of food, or should expose himself to cold or a vitiated atmosphere, it is plain that he must contribute to place him- self in a more unfavourable position, the result of which can only be charged on himself. On the part of the medical attendant, misgovernment may arise either from negligence or bad treatment, by either of which the danger of a wounded per- son may be greatly aggravated. " In general," says Dr. Beck, " when a dissection proves that no wound mortal in its nature has been received, and when none of the circumstances already enumerated can be urged as causing its fatality, the death of the patient should be attributed to the surgical attendant rather than to the author of the wound, provided it can be proved that he neglected the sick person, or maltreated him by leaving foreign bodies in the wound which might have been taken away; by not suppressing he- morrhage ; by not evacuating collections of pus when necessary ; by employing tents unnecessa- rily ; by neglecting or hurrying operations; or by not causing the proper regimen to be observed." (Med. Jur. by Darwall, p. 327, [or Amer. edit ii. 235 : Philad. 1838.] In cases where bodies are found dead from wounds or bruises, a very important question arises which the medical jurist is frequently called upon to solve,—that is, are the wounds the result of suicide, of accident, or of murder ? In the greater number of cases in which our assistance is required, the circumstances of the case are so well known, or can be so proved by witnesses, that there can be no doubt of the cause of injury or of the true author of it. But there are cases in which, to fulfil the objects of justice, it is neces- sary to determine whether the wounds inflicted on an individual were by himself or others. The solution of this question is always delicate, often embarrassing, and very difficult. The circum- stances to be attended to in this inquiry are,— first, the seat of the wounds; secondly, their direction; thirdly, the probable weapon used. There are few wounds that one person can in- flict upon another that may not be accomplished by an individual on himself. Some, however, form an exception on account of their extreme difficulty. For instance, it would be hard to believe that a wound with a sharp-pointed instru- ment in the spinal marrow was inflicted by the individual himself; and in death from fire-arms, wounds inflicted from behind can scarcely be supposed to have been voluntarily effected. In- cised wounds are seldom inflicted except on the throat, for the purpose of suicide ; but instances have occurred where individuals have resorted to wounds of the extremities and amputation of the penis for this purpose. A case occurred recently DEAD, (PERSONS FOUND) 581 within our own knowledge, where the suicide, having failed, as often happens, to destroy him- self by cutting his throat, deliberately bared his left arm, and cut it across to the bone, above the elbow, dividing the brachial artery, from which he bled to death. The circumstance of fire-arms being discharged in the mouth of an individual is sufficient to warrant the belief that it was not done by the hand of another. Thus, attention to the seat of the wound will often determine whe- ther it is the result of accident, suicide, or homi- cide, and will throw light upon the evidence of witnesses as to the circumstances under which the injury was inflicted. The direction of the wound will often likewise, determine the intent, and the question of suicide or homicide. When a wound does not pass through the body, there will be little difficulty in ascertaining the direction in which it came and in which it passes. In a case of supposed suicide by means of a knife or pistol, the course of the wound should be examined, whether it be upwards or downwards, and the length of the arm should be compared with the situation and direction of the injury. It should be ascertained whether the right or left hand has been used ; and as the former is that most com- monly employed, the direction should correspond with it; but if the direction corresponds with the left, it should be inquired whether the deceased were left-handed. When a wound is alleged to have been inflicted by accident, we may inquire into the probability of the statement by comparing the stature of the body with that of the inflictor, and the relative position of the two at the moment the wound was received. In fact, a stab given by an individual of small stature to one of greater size is naturally directed from below upwards, and the contrary if it is the larger of the two who has inflicted it. An example of this occurred some years ago at Marseilles, (Med. Leg. t. iii. p. 195,) in two men of different height, who fought a duel with swords on a public walk. The weapon of each of the combatants reached the heart of the other at the same moment, and they fell dead to- gether. Their bodies being examined, it was found that the wound given by the small man was directed from below upwards, and that by the larger from above downwards. The situation and mode in which a wound is inflicted will often point out the intention of the perpetrator. Fodere (Med. Leg. t. iii. p. 196) relates a case illustra- tive of this point. A miller was assassinated at his own door by a butcher, who pretended that he had no intention of killing him, but had only threatened him with his knife, in consequence of some maltreatment which he had received ; that the miller renewed the attack, and in attempting to pursue him, made a false step and had fallen on the weapon. A single external wound, which led downwards to two wounds of the left ventricle of the heart, separated from each other by an in- terval of two lines, showed that the accused had employed the same method to destroy his victim as that used by butchers in that country to kill cattle; that is, after having driven the knife into the heart, they withdraw it some distance, and replunge it, so as to make a second internal wound. Thus the direction of the wound com- pared with the respective statures of the two ad- 2x» versaries, (the butcher being much smaller than the miller,) proved that the blow had been in- flicted obliquely from above downwards, that is, whilst the miller was sitting at his door, and not by a fall after getting on his feet, in which case the wound must have taken an opposite direc- tion. In the case of wounds from fire-arms perforat- ing the body, different opinions have been formed as to whether this circumstance should determine the distance at which the shot was fired ; and at first we might be led to suppose that if a pistol- bullet passed through, the instrument from which it was discharged must have been very near. But this is found to depend so much upon the strength of the charge, the direction of the ball, and the resistance offered by the parts of the body, that we cannot venture to draw any conclusion from it It is, however, of importance to be able to discri- minate between the entrance and exit wound, as a means of ascertaining the direction of the shot. That made on entering is smaller than the other, and has its edges inverted and depressed, while the latter is much larger, with ragged, everted, and uneven edges, — a circumstance depending upon the direction in which the force is applied to the skin, as well as upon the diminished velo- city of the ball. When flat bones are perforated by balls, the same difference in the size and ap- pearance of the two openings is to be observed. A trial, in which the defence rested upon the dif- ference between the wounds, took place a few years ago in Kent, and is recorded by Dr. Gordon Smith. (Principles of Forensic Medicine, p. 290.) An officer in the preventive service was indicted for the murder of a man who was shot in the night, under circumstances of a suspicious nature as to his pursuit at the time. There was no doubt that he was in company with a party of smugglers, and came by his death accidentally. He was retreat- ing before the prisoner, who tripped, and in the fall his gun went off. It seems that, on the other hand, several shots were fired on the part of the smugglers in their retreat, and that the deceased was killed by one of them. This appeared from £ the testimony of a navy surgeon of considerable experience, who examined the body. He found the wound in the upper part of the groin much smaller than that in the lower part of the buttock, which was twice or three times the size of the former, and was ragged and uneven. Fragments of the bone were likewise felt at the hinder open- ing, but none in the cavity of the pelvis. From these appearances he gave his opinion that the ball had entered in front, and had consequently come from his own party. The probable weapon with which a wound was inflicted will often assist in disclosing the true nature of the accident. The singularity of shape that some wounds present, and the comparison that may be made between them and that of dif- ferent instruments, has sometimes served to illu- minate obscure cases. Such is the case related by Desgranges, and quoted by Fodere, of an indi- vidual, who, having got drunk in a pot-house, left it to return home at eleven o'clock at night, the ground being covered whh snow. He was found dead the following morning, beside a ditch near his own house. Desgranges examined the body, 582 DEAD, (PERSONS FOUND) —DELIRIUM. which at first offered no trace of wound, bruise, or violence; but on turning the head from left to right, an oblique wound was discovered, scarcely three quarters of an inch in extent, under the base of the lower jaw, and about the height of the larynx. The little finger introduced into this wound showed it to be wider and more extensive jwjthin_tfwrrr"appeared from the external incision. The clothes of the deceased were stained with blood, and there was a large quantity poured out on the snow. It appeared that this wound had been inflicted with an auger, which the deceased had carried out of the pot-house under his arm, with the point foremost, and upon which he, being drunk and hardly able to walk, had fallen. This instrument was found lying beside him covered with dry blood, having been extricated by the deceased from the wound, but not before it had wounded the Jeft carotid artery. While upon this point, we think it well to in- sert the declaration of Sir Everard Home, relative to the remarkable case of the death of Sellis, a servant 0f the Duke of Cumberland, and the simultaneous injury received by his Royal High- ness. Sir Everard's declaration seems to indicate that Sellis had committed suicide after attempting the life of the duke. " I visited the duke," he says, « upon his being wounded, and found my way from the great hall to his apartment by the traces of blood which were left on the passage and staircase. I found him on the bed, still bleed- ing, his shirt deluged with blood, and the drapery above the pillow sprinkled with blood from a wounded artery, which puts on an appearance that cannot be mistaken by those who have seen it This could not have happened had not the head been lying on the pillow when it was wounded. The night-riband, which was wadded, the cap, scalp, and skull, were obliquely divided, so that the pulsations of the arteries of the brain could be distinguished." » While dressing these wounds, a report came that Sellis was dead. I went to his apartment, found the body lying on its side on the bed, without the coat and neck- cloth, the throat cut so effectually that he could 'not have survived a minute or two. The length and direction of the wound were such as left no doubt of its being given by his own hand ; any struggle would have made it irregular. He had not even changed his position: his hands lay as they do in a person who has fainted. They had no marks of violence upon them. His coat hung upon a chair out of the reach of blood from the bed; the sleeve from the wrist to the shoulder was sprinkled with blood, quite dry, evidently from a wounded artery, and from such kind of sprinkling the assassin of the duke could not escape." (Edin. Ann. Regist. v. vi. pt. ii. p. 19, and Beck by Darwall, p. 308, [or Amer. edit. ii. 93: Philad. 1833.]) Some light may be thrown upon cases of death from fire-arr:is by attention to collateral circum- stances. Thus, in some instances the crime has been brought home to an individual by means of the wadding employed. A case of this kind oc- curred in Fiance in 1818, and a similar one more recently in England; in both of which the wad- ding was examined, and discovered to have been torn from paper found in the possession of the murderer. If the ball is discovered, a comparison of it with the gun or pistol from which it is sup- posed to have been fired may assist in the in- quiry. Thus, in a case of alleged suicide, in which a pistol was found beside the body, on com- paring the ball with the barrel of it, it was found too large to have entered it, and so the question of suicide was set at Test, and attention was directed to detect the murderer. If a flint pistol have been employed for the purpose of suicide, it has been imagined that the discoloration of the fingers from the combustion of the priming would confirm the case as one of suicide ; but this mark, besides being capable of imitation by a crafty assassin, is becoming every day of less value, in consequence of the general application of detonat- ing locks to all kinds of fire-arms. [In the Life of Sir Astley Cooper, by his Ne- phew, (Lond. 1843,) it is mentioned as an evi- dence of the accuracy of observation of that emi- nent surgeon, that when called to see a Mr. Blight, of Deptford, who had been mortally wounded by a pistol-shot in the year 1806, he inferred from an examination of the localities that the shot must have been fired by a left-handed man. A friend of the deceased, a Mr. Patch, then unsuspected, was the only left-handed man about the premises. He was afterwards tried and convicted of the crime, and confessed his guilt before execution. (See, on all this subject, the excellent work of Mr. Taylor, entitled A Manual of Medical Jurisprudence: Lond. 1844.) The means of identifying spots of blood found on the body itself, on the soil, furniture, or clothes, or on the instrument with which death has been in- flicted, have been investigated by MM. Lassaigne, Chevallier, Orfila, Barruel, and others. For the results of these investigations the reader is referred to the works of Devergie, Guy, and Taylor, al- ready cited.] T. E. Beatty. [DEATH, Apparent.—(See Df.au, Persons FOUND.)] DEATH, Sudden.— (See Dead, Persons found.) DELIRIUM.—The term delirium has either been employed without design in a vague and in- definite manner, or it has been purposely used in a very comprehensive sense, and made to include every mode and degree of mental disturbance, from the slight and difficultly-traced aberrations of the argumentative and almost rational monoma- niac, to the muttering and dreamy stupor of a j patient labouring under the delirium of typhoid j fever. All the phases and varieties of mental alienation, whether degrees of melancholy or violent madness, the wild ravings of the drunkard and the intense reveries of the opium-eater, as well as the peculiar symptoms resulting from that op- pressed and disturbed condition of the sensoriura which exists in severe febrile complaints, are alike comprehended under the designation of de- j lirium when thus extensively applied. But there are few common characters belonging to all these phenomena, and for the sake of distinct and ac- curate description they must be separated. Those which are associated with madness form a par- ticular group, and they may all be set apart under that head. (See Insanity.) Under delirium or DELIRIUM. 583 febrile delirium we shall here survey the disor- dered states of the sensorium and intellect which occur principally in fever and inflammatory dis- eases, and in some disorders affecting primarily the brain itself or its investing membranes ; and we shall point out the characters which distin- guish these from the other phenomena, frequently though improperly included with them under the same term. Phenomena. — Delirium supervenes on fever during any part of its course. It occurs in the hot stage of some intermittents, but rarely makes its appearance in typhoid or continued fever until the disease has reached its height, or until the period of strong febrile action is established. It sometimes occurs suddenly, and without any pre- vious sign of disease affecting the head; but much more frequently it is preceded by headach, throb- bing of the temples, heat of the scalp, a flushed and oppressed countenance. Occasionally a slight hemorrhage from the nostrils is the harbinger of a severe attack or exacerbation of delirium. The patient is at first delirious during the short and imperfect periods of sleep, or immediately after he is roused, becoming, when fully awakened, more clear and comparatively collected ; by degrees this lucid interval is less to be perceived ; the indi- vidual becomes more and more incapable of re- flection and mental exertion, and gradually loses the power of recognizing the persons and objects which surround him. The phenomena of delirium, as they appear to the observer and are remembered by the patient, are like those of a feverish and incoherent dream. When, in a state of health, all voluntary control over the course of the thoughts is withdrawn and the mind given up to reverie, there is still, during our waking hours, a continual restraint exercised imperceptibly over the wanderings of the fancy by the lively consciousness of external circumstances and relations. This controlling influence is with- drawn in health by sleep, and in disease by the impaired state of the sensitive power which ushers in delirium, and which goes on increasing as that affection advances, until it terminates in coma or complete stupor. Delirium, then, appears to hold a relation to sleep and to the dreaming state which accompanies sleep, or to be itself but a species of dreaming more intense and profound. Accordingly phenomena are recorded in many cases of delirium, bearing a remarkable analogy to some of the most striking peculiarities of dreams. In dreams the mind is carried back with vivid intensity of feeling to scenes long past, and meals, with greater accuracy than in the waking moment, minute incidents and circumstances. In delirium, when the sensitive power is nearly ob- literated, the memory is occasionally, under certain modifications, surprisingly powerful and active. There are accounts on record, for example, from which it appears that persons labouring under the delirium attendant on fever, or succeeding injuries of the head, have been heard to talk in languages which they had been accustomed to speak in very early childhood, but had for a long course of years disused and totally forgotten. The case of a Welshman has been mentioned, who lay ill for some time in St. Thomas's Hospital, after an in- jury of the head. During the course of his ill- ness he was heard to 'talk Welsh very fluently, but could not utter a word of English : when he recovered, it was ascertained that he had been absent from Wales upwards of thirty years, and had entirely forgotten his native dialect, the know- ledge of which was thus revived by his disease. This statement, which was first given by Mr. Tupper, has been confirmed to the writer of this article by a personal witness. A parallel case is that of a French countess, born in Britany, who had learned the Bas Bretagne or Armorican idiom during her infancy; many years after she had forgotten it, during the delirium of a severe fever, she was heard to talk incoherently in a dialect which to the astonishment of everybody, a Welsh servant understood and interpreted. Dr. Rush, of Philadelphia, used to state that some of the old Swedish settlers in Pennsylvania, who, attaining a period of great longevity, had survived till his time, were heard in many instances during their last hours, in the almost incoherent mutterings which preceded dissolution, to talk in their native language, which, during by far the greater portion of their lives, had been entirely disused by them and forgotten. This restoration of old and effete impressions is accompanied by another phenomenon. When the mind is thus withdrawn within itself, if we may use such an expression, and goes back to the inmost recesses in which are laid up the stores of long-concealed, but, as it seems, never to be ob- literated reminiscence, it not only becomes uncon- scious of external circumstances, or indisposed to the perception of surrounding objects, but even loses the recent impressions of memory. Newly acquired ideas are effaced, like the immediate im- pressions of sensation. The knowledge of some language but lately acquired has been thus lost. A foreigner, mentioned by Mr. Abernethy, met with an injury of the head when he was twenty- seven years of age. During the delirium which ensued on this accident he could only answer questions in French, though he had previously spoken English perfectly well. He said that he was but sixteen years old, the age at which he left his own country : it is probable that the im- pressions received during eleven years had been effaced from his mind. After accidents which have occasioned concussion of the brain and con- sequent delirium, persons have lost all recollec- tion of events which occurred during a certain period antecedent to the injury. Two gentlemen, intimately known to the writer of this article, met with accidents which occasioned to both of them severe injuries of the head. In both, concussion of the brain was followed by stupor, and after- wards by delirium, which continued some weeks. Both of these persons recovered their faculties perfectly, but each of them had permanently lost all recollection of objects and incidents which had occupied his mind for a considerable time pre- viously to the accident. During the state of unconsciousness as to ex- ternal impressions, there is, together with excite- ment of memory, sometimes a considerable degree of mental activity: the mind is exercised even in forming new combinations. Many persons have 584 DELIRIUM. been known to compose verses and speeches, and to hold conversations on abstract subjects with in- dividuals whom they imagined to be present. Persons labouring under delirium are at times capable of being roused by external impressions, and, when once excited, they display unexpected muscular energy, which is followed by exhaustion, but not in every instance by a relapse into deli- rium. Van Swieten has twice mentioned the case of a man who, under severe delirium, was roused by hearing the noises occasioned by a fire which had brokon out in a neighbouring house. His incoherent muttering, which had continued for some days, ceased, and he inquired anxiously into the cause of the alarm: his delirium was cured from that time. A patient lying ill with fever some years ago, in the Bristol Infirmary, was suddenly roused by a loud peal of thunder. He started from his bed, and in a moment leaped over the beds of the patients who lay in a row opposite to him, and before anybody could lay hands on him, although in the middle of the day, when all were awake, he climbed up to an open window, twelve feet in elevation from the ground of the ward, and almost accomplished his design of throwing himself out of it. He would inevita- bly have been dashed to pieces if his foot had not providentially fixed upon a projecting ridge below the sill of the window, by which, as well as by one hand grasping the window-frame, he was supported until ladders were placed on the outside of the building, by which he was taken down without injury. This man afterwards recovered. When delirium terminates fatally, it passes into coma. Sensibility becomes more and more im- paired, until all conscious feeling seems to be lost. Inarticulate moaning succeeds to delirious inco- herence; the patient loses in a great measure sight and hearing; the pupils become scarcely contrac- tile, and the evacuations escape without conscious- ness. Patients have recovered after remaining for some time in this state, and this has happened not unfrequently in the case of young subjects. But the symptoms above detailed are more gene- rally followed by others, which are the sure har- bingers of death. These are ffocci volitantes, picking the bed-clothes, convulsions, coma, with subsultus tendinum, the eyes being turned up with a falling lower eye-lid. One of these symptoms alone denotes great danger, but the aggregate an- nounces the speedy approach of dissolution. Diagnosis.—The diagnosis between delirium and insanity is, in practice, for the most part at- tended with little or no difficulty. The presence of inflammatory or typhoid fever in the former case, and its absence in the latter, is in general a sufficient indication. Mad persons have many of their functions unimpaired; they walk about, eat, drink, talk. The state of a delirious person is quite different. " The insane," says M. Georget, "have frequently the external senses and the power of voluntary motion in a healthy state; they see, hear, taste ; intelligence is in very few abolished; often the mental disorder is confined to a single faculty, or to a limited number of acts dependent on a single faculty; and in those cases in which it appears to be the most extended, in intense maniacal affections for example, the facul- ties appear to be perverted, or insulated, and with- out the bond of association, but are yet far from being extinguished: the most irrational maniac talks, reasons, wills, and is not always absurd in his reasonings and actions. In the delirious, on the contrary, all the cerebral functions are severely affected ; there are no correct sensations, connect- ed ideas, or passions; no regular voluntary mo- tions ; little or no intelligence or recollection: the patient is almost a stranger to every thing that surrounds him as well as to himself." We may on the other hand observe that most insane per- sons have the digestive or nutritive functions in a sound state, and that they display the external appearances of health, especially after the few first days from the commencement of their insanity, and before they have shown signs of the secondary disease which is destined to bring them to their end: in delirious persons these same functions are always more or less in a state of disorder. We should in fact incur no danger of contradiction from persons who are in the habit of seeing cases of insanity, if we were to venture on the assertion that a great number of lunatics bear infinitely greater resemblance to individuals in perfect health than to patients labouring under febrile delirium. It is of great importance not to confound these two species of mental disorder. The cerebral af- fection which is connected with delirium is in general severe and of short duration; it must be combated by a vigorous method of practice in order to prevent a fatal termination : madness is of long duration, and seldom or never attended with danger to existence. The latter disease seems to pursue its victims even after their re- covery, by the mistrust which they inspire as well for the present as for the future; a mistrust which even extends itself to their posterity. A patient who recovers from this state is often painfully affected at finding himself in a mad-house. It would be unfortunate, on account of these con- siderations, to take a patient labouring under de- lirium for a lunatic; and in doubtful cases the physician should only describe the state of the intellectual faculties by the terms «delirium' or •disorder of the brain' until he has clearly re- cognised and is satisfied of the existence of madness. The leading criterion between delirium and in- sanity is afforded by the state of the sensitive power or of the faculties of sensation and percep- tion. Insane persons have the faculty of sensa- tion generally unimpaired ; and if they apprehend external objects to be different from what they really are, the error lies not in any disordered state of the perceptive power itself, but in the perverted judgment or false conviction of the un- derstanding, which is so deeply rooted as even to resist the evidence afforded by the senses. An insane woman is convinced that her husband is dead; and when he actually comes to visit her, and to dispossess her of this hallucination, she in- sists that the devil has assumed the form of her deceased husband in order to impose upon her. A delirious person cannot distinguish one indi- vidual from another, and sometimes does not know the nurse who constantly attends him. There are, however, cases of delirium approach- ing somewhat to mania, in which the sensitive DELIRIUM. 585 power is but little impaired, and some of the peculiarities of insanity show themselves. We have witnessed the display of cunning and stra- tagem by patients slightly delirious; artful plans laid, in order to get rid of annoyances and to gratify inclinations; a strong impression mani- fested by the patient that he is whure he is not; a concealed suspicion that it is intended to carry him off and put him into confinement We have known instances in which traits of this descrip- tion have excited great alarm, lest what had been regarded as temporary febrile delirium might prove to be a permanent loss of reason. These fears have proved groundless. The faculties are fully restored after having been obscured under febrile delirium, with very rare exceptions. The restoration to mental vigour is, however, in some instances slow, and occupies several weeks, and even months. Facts, indeed, have occurred within our know- ledge which have seemed to indicate that the in- tellectual faculties have been in some instances even brighter and more vigorous than ever, or at least have been exercised with greater activity, and more displayed after a recovery from febrile delirium; and a parallel observation has been made by some of the older medical writers. Pathology. — Many practical writers have been led by observation to conclude that there are two different states of the system accompanied by delirium, in one of which the brain is not the actual seat of disease, at least to any great extent, its functions being disturbed in consequence of disease, for the most part of intense degree, exist- ing in some distant organ; while in the other form of delirium the brain or its enveloping mem- branes is the seat of inflammation. It is very important, in a practical point of view, to dis- tinguish these two affections, which may be termed sympathetic and idiopathic delirium. 1. The first-mentioned species of delirium was indistinctly described by Dr. G. Fordyce, in his minute detail of the symptoms of fever. Fordyce was of opinion that this form of delirium ought to be treated with slight anodynes and restoratives. M. Dupuytren has given to this species of disease the designation of nervous delirium : he has de- scribed it in the " Annuaire Medico-Chirurgical des Hopitaux." He remarks " that it is frequently observed in highly susceptible or nervous indi- viduals, who have received severe wounds, or have undergone painful operations; in those who have suffered greatly from the apprehension of under- going operation, and in others who have made efforts beyond their physical strength to display fortitude and courage in bearing pain heroically ; and, lastly, in persons who have made an attempt to commit suicide." According to M. Dupuy- tren's observation, cases of this description are never cured or alleviated by antiphlogistic reme- dies, but yield easily to the administration of nar- cotic injections. In the brain no traces of disease have been discovered by M. Dupuytren when he has had opportunities of investigating the morbid appearances in cases of nervous delirium. To this form of delirium, as M. Georget has observed, we must refer the various degrees of mental and sen- sorial disturbance which occur at the close of chronic, and even of acute diseases. Compara- tively few persons die in the full possession of Vol. I.—74 their faculties. But it may be observed that chronic affections do not in general excite deli- ! rium and febrile symptoms without passing into a certain degree of acuteness. May we not refer to the same head, as arising from a cause nearly analogous, the wanderings experienced by pa- tients reduced to an extreme degree of weakness on sitting up or rising from bed, as well as the delirium which ensues on excessive evacuations of blood ? Is there not in either case a defect of sanguineous stimulation, giving rise to the dis- order in the intellectual processes ? If we adopt the opinion of M. Broussais on the frequent ex- istence of gastritis, and on the primitive or se- condary causes of febrile action, » the stomach may be the organ which of all others exercises the greatest influence on the brain, and is gene- rally, if not always, the cause of sympathetic delirium : but this opinion cannot be regarded as established." The opinion that defective vascular action or vascular exinanition is a frequent cause of disor- der in the functions of the brain, is a conjecture not peculiar to M. Georget. But the physiology of the brain is not sufficiently known to enable us to follow this conjecture with any thing like a legitimate theory. We only know the fact that long-continued irritation in the system, when the powers of life are giving way, frequently, if not generally, induces, previously to dissolution, more or less of disorder in the sensorial and intellectual functions. This is not the case exclusively in disorders affecting the stomach, or even more fre- quently than in complaints situated in other or- gans. Inflammations of the chest, phthisis, chro- nic ulcerations in the bowels occurring as the sequela? of fever, and a variety of other disor- i ders, often give rise to the kind of delirium here spoken of. This species of disease has often been compar- | ed to delirium tremens. Its phenomena have but little resemblance to the symptoms of that com- plaint, whatever analogy may subsist between the unknown causes of both. They are alike in one respect, viz., as to the inutility of antiphlogistic remedies. It cannot be said that anodynes are equally serviceable in either; they are, however, in some instances of both diseases to be preferred to all other remedies. 2. Idiopathic delirium is a disease of greater importance than the secondary or sympathetic species, inasmuch as it denotes a specific condi- tion of the brain, which requires a particular class of remedies, and which, unless removed by the timely and vigorous administration of such reme- dies, will speedily extinguish life. It is more marked in its symptoms, and more readily traced to its exciting causes : there is, therefore, not much difficulty in general in ascertaining its ex- istence. This form of delirium, likewise, some- times leaves behind it vesliges which may be dis- covered on dissection. Such are all the various phenomena produced by inflammatory action in the meninges and in some parts of the brain. These morbid changes are, however, seldom of great extent. They consist chiefly in vascular injection of the surface of the brain, increased hardness in its substance, effusion of fluid in the ventricles, injection of the vessels in the pia ma- 586 DELIRIUM. ter, serous infiltration of the same membrane : a similar condition of the arachnoid has been, as M. Georget observes, less frequently discovered. More important lesions than these have been traced in cases which combined paralytic or convulsive affections of the muscular system with delirium ; but the latter cannot be considered as belonging to the disorder now under consideration. To the idiopathic form of the disease belong, a. Delirium following injuries of the head, fractures, concussions, wounds, and lesions of va- rious kinds, which produce inflammation either immediately or after the first effects have sub- sided. b. Delirium accompanying inflammation of the brain or its membranes, brought on by exposure to heat or cold. The effects of insolation, and of exposure to heat in furnaces or heated workshops, come under this division. c. Delirium the result of intoxication, or of ex- cessive doses of opium or other narcotics. We allude here, not to the state of intoxication iteelf, but to a more severe disease which is often the sequel of intoxication. Of this cases frequently occur in practice. A theatrical performer came home to his wife in a state of intoxication. Dur- ing the whole night and a part of the next day he was supposed to be merely drunk, and no alarm was taken. As he continued to be delirious on the following day, medical assistance was requir- ed. He was still in a state much resembling that of intoxication: his head hot, face flushed, eyes red, mind confused, but without coma or paraly- sis. His head was shaved, and the jugular veins opened. He expired in the course of the day, and the surface of the brain was found highly injected, the white substance iteelf presenting abundantly bloody points. A man drank by mis- take a poppy-head fomentation. He was seized with violent phrenzy, but speedily relieved and cured by means of bleeding and powerful anti- phlogistic remedies. d. Delirium occurring in erysipelas affecting the head is plainly of this kind. Wc have re- peatedly seen the morbid phenomena denoting inflammation strikingly displayed on opening the head in cases of this description. The metastasis of dropsy, of rheumatism, and of various other diseases, when apoplexy is not the consequence, gives rise to delirium, which may be termed idio- pathic, whatever organ had been affected before the disease was transferred to the brain. e. Delirium attending continued fever is of this kind, when the head is the actual seat of the most intense diseased action. When the fever has been of that kind which some writers have term- ed cephalic, when the ordinary signs of determi- nation to the head, or of increased vascular ful- ness have preceded and accompanied it, delirium may be considered in cases of fever as an inflam- matory complaint. The practical consideration of this subject will be entered upon more fully under the head of Fkvku. We now proceed to make some observations on the treatment of deli- rium. Treatment.—The treatment of febrile deli- rium may be reduced to very simple principles, and these are such as are very generally under- stood. Shaving the head, the application of cold wa- ter, with the admission of free air, are means often adequate to the removal of delirium as it occurs in typhoid fever. We have seen many patients brought from close and foul apartments with typhoid symptoms and labouring under deli- rium, who, after undergoing these simple reme- dies, and passing a single night in a cool, well- ventilated ward, have been found on the next morning so much improved, and so collected and free from mental disturbance, as to require no par- ticular remedy directed to the state of the head. Topical bleedings, viz. either by opening the temporal artery, by cupping on the head, or on the nape of the neck, or by the application of leeches to the head or round the neck, are well known to be among the most important remedies for febrile delirium. Cold applications, by iced water or merely wet- ted cloths, by a stream of water passed by means of a funnel over the vertex, by ice pounded and put into a bladder or oiled skin, or by evaporat- ing lotions, are next in point of importance to bleeding. Blisters to the nape of the neck are often of great service. When the heat of the scalp is not great, or has been reduced, and especially when there is much stupor, or a tendency to coma, blisters are beneficially applied to the vertex. Incisions in the scalp, made in the direction and over the sagittal suture, are of great service in cases of delirium combined with stupor, whe- ther occurring in the course of fevers, or in affec- tions of the head otherwise brought on. The in- cision should reach from the vertex to the anterior part of the hairy scalp, and be made down to the pericranium. The effect of this remedy is often an immediate relief by the bleeding which takes place. The subsequent inflammation and suppu- ration, the incision being kept open, are much more productive of benefit than the ordinary super- ficial inflammation excited by blisters, or the se- rous discharge from the surface of the cutis. The writer of this article has now a patient who is making progress towards recovery, and is al- ready almost convalescent. His improvement appears to have resulted from the means last de- scribed. He laboured under severe delirium with stupor, and had occasional fits of convulsion. His disorder was brought on by exposure to heat, his occupation being that of supplying with coal, and attending to the boiling apparatus of a steam- engine. Purging is of great benefit in cases of idiopathic delirium, and is often sufficient alone to the re- moval of the disease. We shall not proceed further at present in the consideration of remedies required for the treatment of delirium. The morbid state of the brain, from which delirium arises, seldom forms a distinct and entire disease. When it occurs in fevers, the remedial treatment belongs to the therapeutics of fever: when it proceeds from in- juries of the head, it comes under concussion of the brain, or fracture or wounds of the scalp, &c To articles on these several subjects in the pre- sent work, or to distinct treatises, we must refer our readers for more particular details. J. C. Prichard. DELIRIUM TREMENS. 587 DELIRIUM TREMENS. Amongst the nu- merous maladies which are. the results of vicious indulgence, those of which the foundation is laid in the abuse of ardent spirits, and other diffusible stimuli, form a long and frightful catalogue : in- flammation of the brain and its membranes; of the pleura ; of the stomach ; of the liver; jaun- dice; dropsy ; diabetes ; gout; mania ; dyspepsia, with its manifold miseries—these are among the diseases induced by habitual intemperance ; and several more might be added to the appalling re- cital. Place this catalogue before the man who is be- ginning to acquire a taste for inebriating liquors, and he will feel alarmed ; he will probably express his astonishment at the infatuation of the drunk- ard, and his determination to halt at once in his destructive career. Happy is it for such an one if his conviction of danger be abiding as it is powerful: unfortunately, however, it is in too many instances speedily effaced. Temptation again and again offers itself, and triumphs over repeated sober resolves, till, in the sequel, the vic- tim persuades himself that it is absurd to forego a positive pleasure through fear of remote and contingent evils ; of maladies which hundreds, more intemperate than himself, escape altogether ; from many of which recovery is not uncommon ; and to the visitation of which even the ascetic is liable. For some time, perhaps, he is guilty of excess only on extraordinary occasions; but, by insensible degrees, he slides into the habit of drinking deep in all companies, and, at last, of indulging even in private, and at all hours. From what is termed a pleasant companion, he degene- rates into a hard drinker, and ends a complete sot. Still he is attacked by none of the formidable diseases above enumerated, excepting dyspepsia, which he is very unwilling to ascribe to its true cause; or respecting the real source of which he is perhaps actually deceived, owing to the tempo- rary relief which the application of fresh stimuli constantly affords him. His bane and antidote are one and the same. But he who abandons himself to incessant or immoderate potations should know, that if he escapes those diseases which once created such alarm in his mind, he is yet obnoxious to one not less formidable, which some- times manifests itself rather suddenly, and speedily destroys the patient; sometimes creeping on by slow and almost imperceptible degrees, though it may not prove immediately fatal, may still leave him in a lamentable state of debility both of body and mind, and materially abridge the term of his existence. This disease has received a variety of appella- tions. It has been called brain fever, a peculiar disorder of drunkards, delirium et mania e potu, [cenomania, mania e temulentia, delirium po- tatorum, d. tremifaciens,] delirium ebriositatis, erethismus ebriosorum, encephalopathie crapu- leuse, [folie des ivrognes,] delirium tremens. The latter designation is here adopted, not as being altogether appropriate, for if is confessedly open to more than one objection. It is not perhaps quite correct to speak of a delirium as trembling,- and the term is yet more faulty, inasmuch as tre- mor is not an invariable, though it be a very usual symptom. But the designation first employed by Dr. Sutton is that under which the disease has been commonly recognized since the publication of his valuable essay. That essay, though it was not the first distinct notice on our present subject, was the first which seemed to attract the attention of the profession in general to a subject previously little known. The earlier labours of Drs. Pear- son and Armstrong, important as they certainly were, excited less interest. It has been observed by Dr. Blake, that traces of this affection may be discovered in the writings of ancient authors, even as far back as those of Hippocrates; and it is j true that, under the heads of phrenitis, mania, &c. cases are recorded by them of which the symp- i toms bear an intimate resemblance to those of delirium tremens ; but that those cases differed | materially from others of true phrenitis or mania, | seems not to have entered into the minds of the | venerable fathers of medicine. Their successors, I from age to age, overlooked the peculiar character of the disease. Not many years ago the most distinguished lecturers offered nothing, or, at all events, nothing precise upon the subject—except- ing Dr. William Saunders. (fSee Sutton's Essay, I p. 4—note.) Systematic writers were silent con- | cerning it. The first distinct account of delirium | tremens was from the pen of Dr. Pearson, who, | it would seem, derived his information from Dr. i Young, of Newcastle-upon-Tyne. Dr. Armstrong j next published a paper or two upon the subject, [ and he was followed by Dr. Sutton. Since the appearance of his essay, the disease has again been treated of by Dr. Armstrong, in his lectures, and by several other authors of reputation, both of our own and of foreign countries : it has ob- tained a place in the works of Good and of Gre- gory, though unfortunately they differ as to its classification; the former placing it undei nervous, the latter under inflammatory affections. It is now fully recognised as a peculiar disease, requiring peculiar treatment, and therefore one which it is of the utmost moment we should be able to dis- tinguish from certain others to which it bears no inconsiderable resemblance, and with which it often has been, and probably often is, confounded, to the great detriment of the patient, as well as to the discredit and mortification of the practitioner. In describing the phenomena of delirium tre- mens, we shall adopt Dr. Blake's division of the disease into three stages, not merely as conve- nient, but as founded upon a philosophic view of the subject. The advantages of considering deli- rium tremens under separate stages have not been overlooked by other authors; but Dr. Blake's arrangement seems, upon the whole, best calcu- lated to obviate the obscurity and confusion in which its history was formerly involved, and to direct us as to our mode of treatment. The approach of the first stage is announced by symptoms of general debility ; the patient's appearance and manner undergo a certain change; his countenance is dejected and anxious; his spirits are depressed ; there is frequent sighing, and oppression of the praecordia. All around him perceive that he is indisposed, though his most intimate friends may be altogether in the dark as to the nature of his malady, or its cause. If the invalid be himself questioned, he will probably maintain that nothing ails him; or, if he admits 588 DELIRIUM TREMENS. that he does not feel quite well, he will not be able to explain what is the matter with him. Upon more particular inquiry it will be discovered that his nights are restless, that his slumbers are short, and disturbed by harassing dreams ; that he rises in the morning unrefreshed and languid; that his appetite is impaired, or even that he loathes food; that he is annoyed by nausea and continual vomiting; that he Suffers from cramps of the extremities. Vertigo and confusion of ideas are usually present. Pain of head has been reckoned among the symptoms; but it is certainly neither a c >mmon nor a leading one. The tongue is some- times furred, but moist; often, but not in all cases, tremulous. The bowels are generally open. The pulse, according to Dr. Blake, whose opportunities of observing the disease at its commencement have undoubtedly been ample, is invariably slow; and although other writers do not mention this remarkable slowness of pulse, they all concur in representing the pulse as by no means frequent. It is, moreover, soft and compressible; often feeble and unsteady. The temperature of the body generally is not increased, while that of the ex- tremities is considerably below the standard of health. The hands and feet are cold and clammy; the sensation they convey to the touch resembles that observed in persons labouring under enteric inflammation. Tremors of the hands occur in most instances. Such are the principal features of the first stage of delirium tremens, and beyond this stage the disease may not proceed: by timely and judicious treatment its further progress may be anested, and by subsequent prudence on the part of the patient its recurrence may be prevented. Generally, however, it is succeeded, after a shorter or longer period, according to the constitu- tion, age, and previous habits of the patient, by the second stage, or that of delirium. In young and robust subjects, whose excesses have not been of long standing, the stage of re-action or excite- ment will come on much more rapidly than in persons advanced in years, and whose constitu- tions have been broken down by long intemper- ance. It is during this stage that the medical attendant is most liable to fall into error. The symptoms, many of them, are so similar to those of inflammation of the brain or its membranes, that, if he is not especially upon his guard, if he allows the pathognomonic signs of the disease to escape him, his diagnosis will be incorrect and his practice unsuccessful. When the second stage is coining on, the vertigo and confusion of head are more marked; there is more decided aberration of mind ; the countenance gradually assumes a wild aspect; the patient is incessantly restless; there is apparent an anxiety to perforin immediately whatever is desired of him ; he even anticipates your wishes, or what he supposes to be your wishes ; he is peculiarly sedulous in the perform- ance of his ordinary duties, which he goes about in a hurried unmethodical manner; he is very jealous of the least interference, either by advice or otherwise, as to matters pertaining to his voca- tion, exerting himself painfully to prove he is quite well, yet evidently mistrusting himself. Thus, if his occupation is that of a butler, he will betray a strange solicitude about mere matter of routine; he will be in a perpetual bustle; he will commit perpetual blunders, at the expense fre- quently of his master and his guests: his altered countenance, uncertain step, and trembling hands, will sufficiently evince his unfitness for the duties of his situation ; yet he will pertinaciously repel the proffered aid of his fellow-servants; his whole manner will much resemble that of a person on the verge of intoxication, who is excessively anxious to appear quite sober. By ordinary ob- servers he will probably be pronounced more than half drunk, and they will recommend his being sent to his bed, under the notion that sleep will effectually restore him. But such a patient cannot sleep off his malady. He is restless; his mind wanders; he rises worse than he was before, with more symptoms of high nervous irritation. By degrees mental alienation is fully established ; the patient is in a constant worry about some affairs I which he fancies of great importance; some business, generally private business, which must be attended to. He makes violent and repeated efforts to liberate himself from restraint, that he may apply himself to these affairs; but he is not, like the decided maniac, or the man labouring under the immediate excitement of an over-dose of strong liquor, disposed to be mischievous; his exertions, though vehement, are not characterized by malignity or ill nature; he quickly forgets what is past, and, if judiciously managed, is, upon the whole, sufficiently tractable. He will gene- rally take the medicines offered him without much difficulty, and, when exhorted to endeavour to keep quiet, will manifest, for a short time, a desire to acquiesce. He will now and then recognize those of his family and friends who are near him, and will return a rational answer to a few ques- tions ; but he very speedily relapses into his erro- neous train of thought. At this period of the disease the circulation is quickened, the heat of the surface becomes greater, yet still the pulse remains small, and there is a marked difference between the temperature of the extremities and that of the rest of the body, the former continuing damp and cold. If the symptoms above-men- tioned be not soon ameliorated, a sweat bursts out, copious and clammy, and occasionally, it is said, of an offensive odour. The mind becomes still more distressed; objects of the most appalling description sometimes present themselves to the | patient's imagination ; he will be possessed with j the idea that he is persecuted by evil spirits, who are upon the point of carrying firm away, or are preparing to destroy him ; or he may fancy he is I surrounded by assassins ; anil cases are recorded where the unfortunate sufferers actually expired while exerting themselves to the utmost to ward off the violence they supposed was intended them. Catastrophes so lamentable are not, however, of frequent occurrence. Various other hallucinations less frightful, though still very distressing, might be mentioned ; it may, however, be sufficient to observe in a general way, that the mental bias is mostly of the melancholic kind. Sometimes the most whimsical notions arise : thus a patient will imagine that rats or mice, or other troublesome vermin are running over him, or near him ; that he is employed in drawing ribands from the ends of his fingers, with numberless extravagancies of a similar nature. DELIRIUM When delirium is completely established, there is obstinate pervigilium, and this is a very impor- tant, indeed it has been regarded as a pathogno- monic symptom of the second stage of the disease. At this period, too, the countenance assumes au aspect of extreme anxiety; the tremor of the hands and tongue is greater ; the latter is more furred, but still moist; the pulse is not only small but frequent, and also indistinct, partly perhaps in consequence of the tremor and unceasing work- ings of the tendons of the wrists ; the urine is scanty and pale; the bowels are usually confined ; the dejections dark coloured ; the pupils are con- tracted, but without intolerance of light. Still there is no indication of local pain, and when the patient is asked how he feels, he will often reply that he is quite well. These symptoms either in- crease in violence, and others supervening, which very nearly resemble those of the last stage of typhus, the patient dies suddenly in a convulsion; or the long-continued delirium, with subsultus tendinum, picking of the bed-clothes, &c, is suc- ceeded by a short interval of quietude, and he ex- pires without a struggle ; or, after two or three days, or it may be a week, yawning and drowsi- ness come on, and sleep follows, which is gene- rally profound and of long duration, lasting from six to twelve or eighteen hours; the patient wakes collected, and greatly refreshed, and his recovery may be looked upon as almost certain. Such are the general symptoms of the three stages of delirium tremens, which if they be at- tentively considered, and viewed as a whole, will enable the medical student to perceive wherein it differs from certain other affections to which it bears a real or an apparent affinity. When he comes to the bedside, he will be in a good measure prepared to discriminate between a case of deli- rium tremens and one of phrenitis, mania, hypo- chondriasis, or typhus fever. If he be so fortu- nate as to be consulted early, during the first stage of the disease, he will scarcely be at a loss as to diagnosis. But it will more often happen that he is not summoned till the second stage is approach- ing, or until it is fully established ; and then there will be more difficulty in recognizing the affection. There may be certain cognate diseases where ac- curacy of diagnosis is not practically essential, but in very many instances it is of the utmost impor- tance, and on no occasion perhaps more important than when we are consulted in a case of delirium tremens. The previous habits of the patient may be unknown to the medical man ; his friends may be imperfectly acquainted with them, or may en- deavour to conceal them ; to the superficial or the unskilful observer he may appear to be labouring under phrenitis or mania; from himself, of course, no information can be expected. W henever, there- fore, we are called to such a case, we should in- stitute the most careful inquiry into the early symptoms of the complaint, we should endeavour to elicit from the family of the patient what has been his state, both physical and moral, for some time previous to the accession of delirium, and at- tentively view the previous history, so far as it may be furnished us, in connection with existing phenomena—the pulse, the countenance, the tem- perature of the skin, especially of the extremi- ties, its dryness or moisture; the appearance of 2z TREMENS. 589 the tongue ; the degree and kind of alienation, whether the delirium be accompanied with pain of. the head or any other part, with indications of increased arterial action, or of venous congestion, or otherwise ; whether it be characterized by in- tractable violence, or be of a more mild and man- ageable nature ; whether there be tremors of the hands and tongue, which almost always accom- pany delirium tremens from the first, and do not indicate extraordinary danger, while in phrenitis they are scarcely ever present until the last stage, and are then of most unfavourable omen. Having thus detailed the symptoms of the dis- ease, we proceed to say a few words respectine its causes. Now the principal features which mark its first stage so commonly exhibit themselves in intemperate subjects early in the day, when they are in the state of exhaustion which is the usual consequence of a debauch, and have so frequently been observed to arise in soldiers and others, when for a time deprived of their daily quantity of liquor; that the sudden subtraction of accustomed stimuli has been regarded, by respectable authori- ties, as invariably the immediate cause of the disease. The habitual and excessive indulgence in strong liquors, or in other diffusible stimuli, has been considered as the predisposing, and the pri- vation of them as the occasional or exciting cause of the affection. To a somewhat whimsical theory of M. Le- vielle, (Memoires de l'Academie Royale de Med. tom. i. Sur la Folie des Ivrognes, ou sur la Dc- lire Tremblante,) that delirium tremens consists in exaltation of the vital powers of the brain, ex- cited by alcoholic molecules absorbed from the surface of the stomach and bowels, and carried into the current of the circulation, it is objected by Dr. Blake, that he never saw an individual at- tacked with delirium tremens so long as he con- tinued to indulge in his accustomed alcoholic po- tations ; but that it invariably came on when old drunkards ceased for a given time (either from the effects of an excessive debauch, or from any other cause whatever, such as a wound, a fracture, or a fever,) to take their usual inebriating draughts. To overthrow M. Levielle's theory would perhaps cost little labour, but we do not consider that it is in the least degree shaken by the objection just stated; for that delirium tremens may manifest itself in individuals who have never been deprived of their accustomed stimuli, even for an hour, is most certain ; as, for example, in publicans, who live in an atmosphere charged with alcohol,— who, though seldom absolutely intoxicated, are always more or less under the influence of intox- icating liquors—who are sipping from morning to night. Instances of well-marked delirium tre- mens occurring in such persons have fallen under our observation. Interesting cases might be cited, where, upon the patient's being at once removed beyond the sphere of temptation, recovery was rapid and complete ; and others might be adduced in evidence that the habitual stimuli being obsti- nately persisted in, or, after a certain interval of abstinence, foolishly resumed, the disease will pro- ceed to a fatal termination. The delirium which comes on in persons ad- dicted to hard drinking, several days subsequent to a wound or fracture, the traumatic delirium of 590 DELIRIUM M. Dupuytren, the symptomatic delirium tremens of M. Barkhausen of Bremen, and which is re- lieved by ardent spirits or strong liquors of one kind or other, though it be doubtless very nearly allied to the affection which is the subject of our present inquiry, does not seem to be identical with it. In such cases the system receives a sudden and violent shock ; an individual, previously per- haps in the enjoyment of robust health, accus- tomed to strong exercise, engaged in a laborious occupation, requiring much support, is at once confined to his bed ; his habits are in a moment broken off; and no wonder that, in a few days, he falls into a state greatly resembling that of a patient in typhus — a state which absolutely re- quires the stimuli to which he used to resort pre- viously to the reception of the injury. But in delirium tremens, unconnected with other disease or injury, we recognise no such immediate and overwhelming shock. The general health is first perceived to fail; it becomes more and more im- paired ; then come on the characteristic symp- toms of the affection; and, if the habitual stimuli be continued, those symptoms progressively in- crease. From the first the patient passes into the second stage, from that into the third stage of the disease, and he dies. Upon the whole, it would appear that the predisposing cause of the delirium which in intemperate persons supervenes to a wound, a fracture, a fever, &c. is habitual indul- gence in strong liquors, or certain other diffusible stimuli, while the sudden abstraction of such sti- muli is its immediate cause. But in delirium tremens, unconnected with specific disease or ac- cidental injury, the predisposing cause is to be sought in peculiarity of temperament, combined with other circumstances, such as mental anxiety, great and continued fatigue, &c. while habitual intemperance must be regarded as the immediate or exciting cause. We have stated that delirium tremens is caused by the intemperate use of strong liquors, or of certain other diffusible stimuli. Of these latter, opium, either alone or in its various combinations, is the chief. The long-continued and free use of opium may certainly induce true delirium tremens. We have known it to be so produced, and this fact is sufficient to overthrow the theory of M. Levielle, before referred to, which would make the absorption of alcoholic molecules the exciting cause of the disease. It has also been asserted that the poison of lead, that malaria, that long fasting, will produce it; but we think, with Dr. Blake, that where delirium tremens follows ema- nations from lead, malaria, hunger, &c. it is only in subjects in whose constitutions the ebriositatic diathesis has been established by frequent ex- cesses. When delirium from such causes occurs in persons of temperate habits, it will not present the other pathognomonic symptoms of the disease of which we are speaking. We now arrive at an important question, one which we would gladly dispose of in a satisfactory J manner, but which, we fear, must be left in ob- scurity—What is the pathology of delirium tre- mens } Dr. Armstrong, in his lectures, fairly confessed he could not satisfactorily answer the question. The affection, he said, appears to de- pend principally upon some condition of the ner- TREMENS. vous system with the nature of which we are un- acquainted ; and so he left the subject. By Dr. Gregory it is dismissed in terms sufficiently ex- pressive of his doubts respecting it. " It appears," he says, " to have for its proximate cause a pecu- liarly excited state of the nervous system ; but the occurrence of such symptoms in cases of ex- treme inanition would lead to the belief that ex- haustion of nervous power expresses, perhaps, more accurately its intimate nature." It were easy, in this place, to descant learnedly upon cerebral irritation and disorganization; we might I throw additional darkness over what is already I obscure; we might pretend to explain what is | unknown, by something completely unintelligible. I In the absence, however, of just information, either by means of examination after death, or from any other source, we prefer acknowledging I that we are very ignorant as to the pathology of delirium tremens: we do not know in what its intimate nature consists ; but we do know enough to direct us as to practice ; to enable us to state that in delirium tremens, uncomplicated with other serious disease, such as inflammation of some important part, unless circumstances are I peculiarly unfavourable, unless the patient's con- stitution is extremely shattered, or he is very ill— I managed, he will recover from the immediate attack. In simple delirium tremens, occurring in a subject neither far advanced in years, nor com- pletely broken down by excess, our prognosis would be favourable. We may now proceed to the treatment of the disease. And here we would once more strongly insist upon the importance of minute attention to its several stages; since, as each stage presents some difference with respect to symptoms, each will require modification as to the plan of treating it. It may be assumed that the disease is one of debility. Bloodletting, as a general remedy, is no longer thought of. In its first stage, of which the symptoms are entirely those of diminished energy, no practitioner would dream of bleeding, either general or topical. In this stage, (we speak, be it remembered, of delirium tremens uncomplicated with other accidental affection,) there is absolutely nothing but what would contra-indicate abstrac-' tion of blood. The employment of laxative me- dicines will however be needed. The bowels may not be, and indeed they usually are not, con- stipated, yet the stomach and collatitious viscera may fail in the due performance of their respective offices ; the alvine evacuations, though not defi- cient, may be unhealthy. In so disordered a state of the nervous system, as Dr. Gregory observes, the secretions will probably be vitiated. Mild purgatives will commonly suffice; but if, as some- times happens, the bowels are actually constipated, recourse must be had to more active remedies, and amongst these croton oil perhaps is entitled to especial regard, since, beyond its purgative quality, it appears to exercise a peculiar influence upon the nervous system. While in this stage of the disease we deprecate bloodletting, and would, under ordinary circum- stances, employ only mild laxatives, we would not, on the other hand, advocate a highly sti- mulant plan of treatment. Under such treatment patients may now and then recover; but, gene- DELIRIUM TREMENS. 591 rally speaking, the liberal exhibition of accustomed stimuli will be likely to render the supervention of the second stage more certain, to induce more violent re-action, and to place the patient in ex- treme jeopardy. The accustomed stimuli should be withdrawn without hesitation. Neither wine, nor spirits, nor strong malt liquors, should be allowed at all; or at all events they should be administered only in very moderate quantities. Opium should be regarded as our chief remedy ; but at this period it is not to be given in full doses, but in small ones, repeated at short inter- vals. If nausea is present, with disposition to vomiting, or actually vomiting, about ten drops of laudanum, or of Battley's solution, may be given every other hour in au effervescing draught; and anodyne enemata, should the stomach be very irritable, may be employed. If the stomach is re- tentive, and there be no nausea, the above-men- tioned quantity of the opiate, with a few drops of Hoffmann's ether, or (should ether disagree, as it sometimes will, producing a distressing sense of coldness in the stomach,) a few drops of the aromatic sphit ammonia, in camphor mixture or some other grateful vehicle, will be found more advantageous than any of the stimuli to which the patient has been accustomed. The warm bath or tepid affusion should not be neglected. Even cold affusion has been recommended upon highly respectable authority ; but, when we reflect upon the train of symptoms which manifest them- selves in the first stage of the disease, we should scarcely, even in a young and healthy subject, venture upon the adoption of so bold a practice. Anodyne frictions may be employed to the epi- gastrium ; the head may be shaved, and the scalp stimulated by strong volatile liniment; and a blister be applied to the nape of the neck. Eme- tics have been recommended by American phy- sicians; but, as they do not appear to recognize the several stages of the affection, they leave us in ignorance as to the exact period when emetics should be given: they can scarcely be deemed applicable during its first stage; and in the second they would seem to be a doubtful remedy. [By Dr. Joseph Klapp, of Philadelphia, the treatment of delirium tremens was made to con- sist almost exclusively in the employment of emetics. On them at least the main dependence was placed. When the patient is first seen by the physician, it may be advisable, in many cases, to evacuate the contents of the stomach; and at a subsequent period, the equalizing and revellent action of an emetic may be employed with advan- tage ; but it is very questionable, whether much good can arise from the repeated administration of agents whose action may exhaust; and under such feelings, with the absence of any markedly beneficial results from their use in many cases, they are by no means generally prescribed by practitioners.] By the judicious employment of the means just pointed out; by the adoption of what may be termed a stimulo-narcotic plan of treatment, mo- dified according to the intensity of the symp .mis, and the age, constitution, &c. of the patient; the second stage may be averted ; the depressed niv- vous power being gently raised, the necessity for a great remedial effort of nature, for violent re-uc- tion, may be superseded ; sleep may be induced, and the patient awake free from complaint. While upon the subject of treatment in this stage of the disease, we have not touched upon diet, and for this plain reason, that the state of the stomach is usually such as not to admit of anything beyond what is essential in the way of medicine. Should, however, this stage be pro- tracted, and the patient seem to require, or express a wish for food, any mild nourishment, such as arrow-root, sago, or broth, may be allowed him. Should the second stage come on, depletion is, for the most part, still to be avoided ; it is a re- medy not to be employed but with the utmost caution. In young and vigorous subjects, and where there exists evidence of local determina- tion, a single moderate bleeding from the arm, or the application of leeches to the temples or behind the ears, may prove useful; but the bleeding should never be large, and very seldom will it be proper to repeat it; while, generally speaking, it should be rejected as a practice which has too often done mischief, and has not unfrequently destroyed the patient. Opium is, at this period, our sheet-anchor, opium in full doses; all other remedies are of inferior importance. The object is to get down, and that speedily, what experience has proved to be generally effectual. We would recommend laudanum, say sixty minims, every hour or two; such a quantity of liquid may almost always be given without difficulty, while opium in substance may be refused, or its tincture in combination with other medicines may be obsti- nately rejected. The medical attendant should watch by his pa- tient during the exhibition of opium, and steadily persevere for several hours,—not so much regard- ing quantity, as the effect produced. While, how- ever, we thus strongly insist upon the bold and free employment of opium in the second stage of delirium tremens, we would not be understood as advocating its excessive or indiscriminate exhibi- tion. Should the remedy, after some hours, fail to produce the desired effect we must proceed with caution, lest by pushing it too far we add to the intellectual disturbance, and to the danger of our patient. The probability, however, is, that in a few hours there will be a remission of symptoms; that tranquillity will succeed gradually to high excitement, and there will be a disposition to sleep. This disposition will sometimes be attend- ed with slight rigors, which may alarm those who are unaware of their nature and consequences. We should then be more sparing in our adminis- tration of opiates, and allow some time to intervene between the doses. The inclination to sleep should be promoted by every means in our power; every- thing calculated to excite, as light, noise, &c, should of course be studiously guarded against. The first slumber may perhaps be interrupted by starlings, and the patient may soon awake alarmed and distressed; but a moderate dose of opium, with some warm stimulating drink, and a kind encouraging manner ou the part of the attendants, will generally be followed by a sleep more pro- f'uud and of long duration, from which the pa- tient will awake perfectly collected. Anxious not to divert the attention of the prac- titioner, at this so important a period of the dis- 592 DELIRIUM TREMENS. ease, from the one great and principal remedy, we have hitherto said nothing of other curative means; of calomel with the compound ipec. powder, in the proportions of two grains of the former to six of the latter, every two hours, till the system is affected or the disease yields ; of the warm bath; of cold applications to the head; of purgatives; among which we may once more no- tice croton oil, either given internally, or used in the way of friction to the abdomen. These are not to be overlooked ; they are valuable auxilia- ries ; and should opium, after a fair trial, fail us, as it occasionally will, camphor, musk, ether, am- monia, with hyoscyamus, are succedanea not to be neglected. The cautious administration, too, of alcoholic liquors, may, in such cases, be of service. During this stage we must pay particular at- tention to the moral management of the patient. We must strive to obtain his confidence, to gain an ascendency over his mind without having recourse to coercive measures. As patients in delirium tremens are not usually disposed to be mischievous or malignant, physical restraint should be generally avoided : if a man is very uneasy and unquiet in bed, he may be permitted to get up ; and if he is very importunate to go over his house, or is possessed with the idea that he must absolutely examine letters or papers, it will be the part of prudence to yield to his wishes, at least to a certain extent, for by so doing we shall be most likely to gain an empire over his mind; and the satisfaction of his desires, when they are not clearly improper, will probably ob- viate a long and painful scene of impatience and contention, and will favour the return of tran- quillity, and the accession of that sleep so much to be wished for. On no account, however, should the patient be left for a moment without an expe- rienced attendant; and it should be remembered, that although the delirium in this disease is not generally characterised by intemperate violence, instances sometimes occur where it very closely resembles true mania.* Where the unhappy patient manifests a strong disposition to offer violence to himself, or to those about him, every offensive weapon should be removed, and two male attendants be employed to keep the patient within bounds. We say two attendants, because thus the strait-waistcoat may be avoided, which, as Dr. Armstrong has observed, should never be resorted to but at the last extremity. In one word, the treatment of patients in deli- rium tremens should be according to Pinel's directions in other cases of mental alienation. To cut short the disease at this period is beyond our power; our efforts must be steadily directed towards the mitigation of urgent symptoms. Nature is now actively engaged in the work of restoration, and it is the part of the sound physi- cian to be her discreet minister. He may direct her efforts, but he must not pretend to " give them pause." If left to herself, her operations will probably be fearfully energetic: we should endea- vour to regulate the efforts she is making towards a good end. * A medical friend of the writer very nearly lost his life by Hie violence of a patient labouring under deli- riuin tremens. It may, however, happen that all our exertions during the second stage of the disease will prove unavailing ; that the third stage, that of tranquil- lity and sleep, will not be induced by any of our remedies; and that all the untoward symptoms formerly enumerated will supervene. How are we then to act ? We must persist in the same general mode of treatment. We may shave the head, and apply blisters or antimonial oint- ment; we may apply blisters, or mustard cata- plasms to the extremities ; we may employ mer- curial frictions; we may give powerful stimulants. It is incumbent upon us not to omit these reme- dies, though there exists little chance of their proving efficacious. The last symptoms are those of effusion into the ventricles, or on the surface of the brain ; and such effusion to any considera- j ble extent is almost always the forerunner of death. When the event is more fortunate, when the immediate danger is averted, we should support the strength by moderate and frequent supplies of mild nourishment, and the judicious exhibition of diffusible stimuli, gradually diminishing the latter, and after a short time subtracting them wholly. Having thus far conducted the patient,—having placed him in present safety,—the merely profes- sional duty of the physician may be considered as terminated. Something, however, yet remains for him to do if he would be deemed the neighbour of the individual whom he has just succeeded in rescuing from extreme peril. The physician should not lose sight of the convalescent until he has seriously advised him as to future conduct He should avail himself of the mollia tempora fandi;—gratitude, confidence in the talent of his medical attendant, a vivid sense of the danger he has escaped, a present conviction that he has nearly perished through his own folly, will proba- bly incline the patient to listen attentively to counsel earnestly and forcibly urged, yet without the semblance of harshness or the tone of reproach. What the nature of this counsel should be, the medical man need not be informed ; the prophy- laxis in the disease before us is sufficiently obvious. The complete abandonment of previous habits must be inculcated; but to produce a lasting impression, the adviser must speak from the heart. He must, to adopt the language of one who was truly an ornament to his profession, " evince a genuine love of virtue, accompanied by a sincere interest in the welfare of the person to whom his counsels are addressed." Such honest counsels may be productive of an indelible impression; they may conduct to the happiest results, to moral as well as physical restoration; or should they be offered in vain, the physician will retire with at least the pleasing reflection that he has to the best of his ability fulfilled his duty. H. W. Carter. [The plan of treating delirium tremens pursued by the writer, as stated elsewhere (Practice of Medicine, 2d edit. i. 277, Philad. 1844), has been entirely eclectic, and, in many cases, expec- tant, and the results have been such as to satisfy him. Under the view which he entertains of the nature of the affection,—that the irregularity of nervous action is induced by the withdrawal of , an accustomed stimulus, and that the recuperative DELIRIUM powers are, generally, entirely sufficient to bring about the necessary equalization,—he has treated the mass of the cases which have fallen under his care, without either excitants proper, or opiates. In the first instance, an emetic has been given at times, for the reasons above stated ; and, after- wards, the patient has been kept in a state of tranquillity in his chamber—the intrusion of too much light and noise being prevented — and, where the stomach would retain it, gently nutri- tious and easily digestible diet has been prescribed; the bowels have been kept open by gentle cathar- tics ; and this has comprised the essential part of the treatment. In time, the hallucinations have disappeared, sleep has returned, and entire resto- ration supervened. Under the idea, so generally prevalent, that the patient will sink unless stimulants or opium are given, if the attack be severe, the physician is apt to become alarmed, and to fly to those agents; but, should he persevere, he will find that his fears are groundless, and he will be encouraged in his course, when he reflects that, by administering either brandy or opium, he cannot infuse fresh vitality into his patient, and can only act on the excitability that is already present in the tissues. In the female lunatic asylum of the Philadelphia Hospital, the course here recommended has been advised, during the author's term of attendance as one of the physicians to the establishment, and where it has been carried out, the general result has been satisfactory, in more respects than one. It has, in the first place, restored the individual to health—not, perhaps, as rapidly as either brandy or opium, but more permanently. The term " restoration to health" is hardly, indeed, applica- ble to the change effected by the former remedy : the patient is merely placed in the condition in which he was before the stimulus was withdrawn; and, as he was restored by the brandy, he is apt —as before remarked—to regard it as indispensa- ble to his healthy condition. In the " total absti- nence" plan, however, the habit of drinking is broken in upon, and even if it should require a short time longer to restore the individual, there is the consolatory reflection, that delay is not use- less ; as every day's privation of the wonted stimulus diminishes the feeling of necessity, and the desire for it. One evidence of the good effect of the course is, that they who are dismissed cured, rarely, or never, return to the wards. This is an observation that has been made at the Phila- delphia Hospital, and as it concerns paupers, it is probable, that the cures are real and permanent, for were it otherwise, they would, on subsequent attacks, be compelled, in their destitution, to seek the wards of the same excellent charity. Under this eclectic course, it may be advisable, however, in certain cases, to administer both exci- tants and opiates. Where a person has been accustomed for years to the daily use of large quantities of alcohol, the nutritive functions totter under the irregular innervation, and the recupera- tive powers seem to be insufficient to restore the balance of nervous action. These cases are, however, uncommon. In like manner, where sleep has not recurred, after a continuance for some days of the plan above devised, a full dose of opium,—two or three grains, in the form of a Vol. I. —75 2z* TREMENS. 593 soft pill,—frequently forms an excellent adjuvant. There are cases, too, in which the irritability of the stomach is so great, that no food or medicine can be retained, and the patient becomes exhausted by the irritation. A blister, applied over the pit of the stomach, and the blistered surface sprinkled with sulphate or acetate of morphia, (two to four grains at a time,) may allay the vomiting, after which such internal management may be adopted as the case may seem to demand. Dr. M. Hall remarks, that "it becomes a serious question, whether any stimuli should be allowed" in delirium tremens. Our observation and reflec- tion are, in the main, in favour of the negative; and the remark is applicable to the various exci- tant antispasmodics that are wholly trusted to by some, because the disease is characterized by tremors. All these "antispasmodics"—assafoe- tida, castor, &c.—are, like capsicum, mere stimu- lants. They are not possessed of any specific power over the disease, and are never employed by the writer, unless he is desirous of exciting a new nervous impression on the gustatory nerves, and on the nerves distributed to the lining mem- brane of the stomach. The same may be said of the cold shower-bath, or douche. The shock, or new impression, made by it, is at times salutary, but some discrimination is needed in regard to its application to those whose powers are greatly prostrated. Admitting, then, that there may be cases which demand something more than the expectant or eclectic treatment, these cases are certainly small in number ; and a careful classification, by sepa- rating those who are considered to require impe- riously the use of stimulants from those who do not, cannot fail to lead to results in the highest degree satisfactory to the philanthropist: first of all, by preventing the indiscriminate treatment by alcohol adopted by many ; and secondly,—as a consequence of this,—by leading to a more exten- sive reformation in the patients themselves. One of the writer's colleagues in the Philadelphia Hospital, Dr. Gerhard, is an energetic supporter of the method of treating the generality of cases by the free exhibition of alcoholic liquors, and, in j support of it, cites the results observed in the men's wards under his care, from October 12th, ! 1839, to October 12th, 1840. Of 162 cases of decided delirium tremens, 87 were admitted in the first stage ; 73 in the second ; and two in the third : 160 cases recovered, and one remained convalescent, who is since well. " One, only, proved fatal; the patient was admitted in the third stage of the disease, and died in a few hours | after his entrance: he had been treated with opium; and a box of pills, which he was taking, was sent to the hospital with him. Of course," adds Dr. Gerhard, " this apparent exception con- firms the general conclusion, that the disease ter- minates favourably in every instance when treated according to the method recommended." Any inference, however, from a single year's observa- tion, may be fallacious ; and especially may it be questioned, when the results of a similar treatment adopted by the same observer and by others had been previously less markedly favourable. It is a well-known fact, that in certain seasons and years i diseases are more severe than in others ; and the 594 DELIRIUM TREMENS —DENGUE. circumstance, that of the 162 cases of delirium tremens, referred to by Dr. Gerhard as having been admitted in the year ending October, 1840, only j two are classed in the third stage, sufficiently ex- hibits, that the disease must have been unusually mild. The writer has now before him a statisti- cal account of the Women's Lunatic Asylum, at the Philadelphia Hospital, for the years 1840 and 1841, which is under the author's charge during the six months, commencing on the first of November, and ending on the first of May ; and was, at that time, under his colleague, Dr. Pen- nock, for the other part of the year. It may be proper to add, that from November 1st, 1841, to May 1st, 1842, not a drop of alcoholic liquor was used in the treatment of delirium tremens in the Women's Asylum, although some severe cases in the third stage occurred, which, notwithstand- ing, terminated most satisfactorily. Patients treated during the years 1840-41. Cam admitted. Cured. Died. Intoxication,.......44.......44.......0 Delirium tremens— 1st stage, 55.......55.......0 2d stage, 19.......19.......0 3d stage, 10....... 9.......1 The fatal case was not seen by the author. The patient died the morning after her admission, and had been treated in the city for nearly a week previously. It cannot consequently be considered, that the value of the treatment has been settled " upon a more definite basis than has yet been done." The investigations ought to be con- tinued through a succession of years; the differ- ent methods of treatment be compared extensively, and under circumstances as nearly identical as possible, before any such conclusion can be con- sidered established. Moreover, the results ob- tained by Dr. Gerhard,—successful as they were, —are not more so than those recorded by an ob- server already cited, who places great reliance on the treatment by emetics. In a report, made by Dr. Klapp, he states, that of 51 cases, all but one were cured without the use of a grain of opium, or a drop of alcoholic drink of any description;— the unsuccessful case died of epilepsy. Robley Dunglison.] [DENGUE. This singular name for a dis- ease,— according to Dr. Dickson, of Charleston, whose essay (on Dengue, Bell's Med, Library, for 1839) has furnished the main material for every thing since written on the subject,—was de- rived from the English negroes of the Island of St. Thomas, where the disease prevailed, who called it the " Dandy Fever," owing to the stiff, affected gait induced in those labouring under it. When the disease occurred in Cuba, the word « Dandy" was corrupted in Spanish pronuncia- tion into "Dunga," or "Dengue," by which it was known in the southern states. It first made its appearance in the Caribbean Islands in 1827, whence it spread over the West Indies, and in the following year to the southern coast of the United States. It prevailed in New Orleans in May and June ; and in July and August affected very severely the inhabitants of Charleston ; reach- ing Savannah in September and October. At the close of the year, it became gradually extinct, and has never since recurred. " In its brief dura- tion," as remarked by Dr. Dickson, (op. cit. p. 6,) " in the suddenness of its appearance, in the rapi- dity of its spread, and in its total subsequent ex- tinction, offering a striking resemblance to the Black Death of the fourteenth century, and the Sweating Sickness of the sixteenth, and several other shapes of pestilence, which have at different points of time arisen and died away, scattering among the nations horror and affright." " Hap- pily, however," he adds, " as the record will show, it was much unlike these plagues in proportional mortality ; bringing in its train infinitely less of danger and of death than of mere suffering." Diagnosis.—The disease was generally ush- ered in by febrile symptoms of an inflammatory character, accompanied by a painful affection of the joints and muscles. On the second or third day, the fever declined, and with it the articular pain,—the attack terminating in a copious perspi- ration, occasionally attended with a rash or miliary eruption, which was esteemed, however, as only an incidental symptom. On the third or fourth day, the fever having in the meantime intermit- ted, more or less gastric disorder appeared, and on the fifth or sixth, a cutaneous eruption, which re- sembled scarlatina more than measles, but was less confluent than either of those affections, and consisted of minute florid red papulse, slightly elevated, and distributed in irregularly shaped patches, appearing first upon the face and trunk, and spreading to the extremities. On the full de- velopment of the eruption, a second febrile exa- cerbation, with severe arthritic and muscular pains occurred. After two or three days' duration, the eruption gradually disappeared, with some de- squamation of the cuticle. In some cases, the lymphatic ganglions of the neck, groins, and axilla remained swelled for a long period. Of all the symptoms the affection of the joints was most tenacious and troublesome, adhering for weeks to some, and constituting a sort of perma- nent lameness. A sore mouth was a frequent symptom, and in one or two instances there was pretty severe glossitis. In regard to the pathology of Dengue, there has been difference of sentiment. Dr. Dickson, (op. cit. p. 8,) classes it among the exanthemata; whilst the union of an eruptive fever with an in- flammatory affection of the joints gave occasion to its names, scarlatina rheumatica, exanlhesis arthrosia, and eruptive articular or rheumatic fever. Causes.—Opinions have varied on this matter. Dr. Dickson is disposed to regard it as contagious. Drs. Osgood and Lehman, who saw it in Cuba, seem disposed to regard it as the ordinary fever of that region, under certain peculiarities of cir- cumstances not well explained ; and Dr. Waring, of Savannah, dwells upon its close analogy with the break-bone fever of 1826, and the epidemic bilious remittent fever of 1827 in that city. Still closer, according to Dr. Dickson, (op. cit. p. 11,) are the points of similarity which may be found in the history of the break-bone fiver or remittent described by Dr. Rush as prevailing in Philadel- phia, in the summer and autumn of 1780, and the epidemic of Calcutta and Berhamporc, pour- tray ed by Dr. Mellis in 1824-5. The prognosis was exceedingly favourable. Per- haps no form of disease is known, in which the DENTITION. ' 595 proportion of deaths was so small compared with the numbers attacked. The aged were most se- verely handled,—remaining frequently infirm and debilitated, with languor and emaciation. In the intemperate it served to usher in formidable pa- roxysms of delirium tremens. When it did prove fatal, it appeared to be owing to complications. Treatment.—The lancet was generally found necessary during the inflammatory period, with cathartics and antiphlogistics. Anodynes were likewise needed to relieve the violence of the pain. Robley Dunglison.] DENTITION, Disorders of. Under this head we shall endeavour to collect, not all the affections which hereditary errors and popular prejudice have marshalled under it, but such as careful and unbiassed observation has demon- strated to be occasionally induced by the process of cutting the teeth. By adhering to this resolu- tion, a subject, once of interminable length and exaggerated importance, may be brought within comparatively narrow bounds, and if it be cur- tailed somewhat of its mysterious interest, it will not, we trust, lose in respect of practical utility. The operations of nature are usually conducted in so skilful and complete a manner as should in- spire all reasonable minds with large confidence in her powers, and lead them strongly to doubt all those hypotheses which would make disease a necessary adjunct to the evolution of our corpo- real frame. That artificial modes of life, on the other hand, together with injudicious manage- ment, an excess of Hutriment, with deficient exer- cise, impure air, and the other causes which tend to derange the general health, must greatly in- crease the difficulty and danger of the process of dentition, is indubitable; but that the mortality fairly traceable to it should, under any circum- stances, have been rated so high as one-tenth and even one-sixth of all the children who undergo it, cannot fail to excite our surprise. Children, as well as adults, are liable to nume- rous diseases of the three great cavities; but the difficulty of accurately recognizing them - in early infancy too frequently causes their true nature to be overlooked, and disorders which are really idio- pathic to be considered merely sympathetic affec- tions depending on the process of teething. Dentition, though often difficult and painful, is not in itself, properly speaking, a disease ; yet the excitement which it produces is favourable to the development of such complaints as there exists a tendency to at this time of life. It is indeed the most critical period of childhood, and the super- vention of any serious disease, as sinall-pox, mea- sles, &c, during its progress, is, from the increas- ed sensibility of the whole system, attended with more than ordinary danger. The first Dentition. — The rapidity with which the first set of teeth is developed necessa- rily causes a considerable determination of blood to the head, a circumstance which assists us in explaining many of the morbid tendencies which at this time occur. The rapid evolution which the brain, also, is at this period undergoing, con- curs in a still more powerful degree to heighten the nervous susceptibility. This stage of exist- ence is, indeed, remarkably characterized by a ten- dency to cerebral affections ; and diseases of the chest, abdomen, and other parts, often become complicated with them, or towards their termina- tion merge into them. The irritable constitution and extensive sympathies which distinguish in- fancy, help us to account for the severity of the symptoms which sometimes occur from teething. As the child grows older, though the local affec- tion may be equally violent, the intensity of the constitutional effects is generally much diminish- ed, and accordingly we find that the cutting of the large double teeth occasionally gives rise to much less disturbance than that of the smaller teeth which preceded them. Any unusual obstacle to the coming forward of the teeth, such as may be caused by a dispro- portion between their rate of development and that of the jaw; or even their too rapid progress and the consequent appearance of several of them simultaneously, must greatly augment the dis- turbance produced by this process. The rudiments of the teeth are visible in the foetus about the second or third month. As they increase in size, they are found to consist of a double membranous sac, from the bottom of which rises a pulp composed of a vascular and nervous substance, and surrounded by a colourless fluid of a mucilaginous consistence. This fluid is gradually absorbed as the pulp enlarges, and os- sific matter becomes visible on the summit of the latter about the end of the third month. The enamel is subsequently formed, but whether by deposition from the fluid, or by secretion from the inner and vascular membrane of the sac, is a dis- puted point The jaw at first presents only a channel along its edge; but by the growth of transverse bony septa, this is subdivided into cells, and the alveoli are thus formed. The germs of most of the permanent teeth are visible even in the foetus, and are situated behind and below the milk teeth. At the period of birth the ossification of the teeth is already far advanced, the crowns of the incisors being usually completed, and a consider- able part of those of the double teeth formed. The ossification of their roots is a subsequent process, and in proportion as it advances, and as the alveoli become developed, the crown of the teeth is propelled towards the surface of the gum, and by the gradual absorption of this, and of the apex of its own enveloping sac, at length makes its appearance externally. The pressure on the membrane and gums, and the consequent irrita- tion which accompanies this 6tage of the process, give rise to the painful symptoms of dentition. The milk teeth are twenty in number: they usually appear in pairs, and those of the lower jaw generally precede the corresponding ones of the upper. They succeed each other commonly in the following order : first, the middle incisors ; next, the lateral incisors; then either the canine teeth or the anterior molars,—perhaps more fre- quently the latter,—(but not invariably so, as M. Serres would have us believe;) and lastly the pos- terior molars. The first incisor is generally cut about the sixth or seventh month, although occasionally not for many months later; the canine teeth commonly appear about the fifteenth month; and the poste- 596 DENTITION. rior molars at various periods from the twentieth to the thirtieth. Thus, the whole period occupied by the first dentition may be estimated at from a year and a half to two years. Such is the usual process of dentition ; but it varies considerably in different individuals, both as to its whole duration, and as to the periods and order in which the teeth make their ap- pearance. In scrofulous children, according to Gardien, the first incisors are occasionally cut so early as the third or fourth month ; but such teeth are apt to decay and soon drop out. Un- derwood, on the other hand, has known weakly and rachitic children to be still without a tooth at twenty-two months old ; and in such subjects analogy would certainly lead us to expect the ossification of the teeth to be tardy and imperfect. The premature and rapid development of the teeth has occasionally appeared to Guersent to be, not the effect, but the exciting cause of rachitis and tubercles: and, in general, it may be stated that the greater the number of teeth coming forward simultaneously, the greater the danger: those who have them late usually suffer least. Numerous instances are on record of children who were born with some of their teeth already cut; of which Richard III., Louis XIV., and Mi- rabeau, were notable examples. In the case of Louis it was brought forward, but fallaciously, as an argument to establish his legitimacy, on which the lateness of his posthumous birth had thrown suspicion. Such premature dentition is neither a proof of protracted pregnancy, nor yet of a strong constitution in the infant, as it has been observed that such children are often unusually small, and most frequently die early. Indubita- ble instances are mentioned by authors, of indi- viduals who never had any teeth: Borelli knew a woman of sixty years of age in this predica- ment : certain diseases of the jaw affecting the germs of the teeth may be occasionally the cause of this singular phenomenon. Soemmering and Fox each saw a case where several of the teeth were consolidated into one mass; and we have met with a similar instance in the Museum at Leipzig, of two incisors grown together by their crowns, whilst the roots are separate.* Such ab- normal appearances depend, no doubt, on the de- ficient evolution of the alveolar septa. The natural symptoms of dentition in its mild- est form are an increased flow of saliva, with swelling and heat of the gums, and occasionally flushing of the cheeks. The child frequently thrusts its fingers, or any thing within its grasp, into its mouth. Its thirst seems to be increased, for it takes the breast more frequently, though, from the tender state of the gums, for shorter pe- riods than usual. It. is more fretful and restless, and sudden fits of crying and occasional starting from sleep, with a slight tendency to vomiting and diarrhoea, are not uncommon. Many of these symptoms often precede the appearance of the * In the same museum, which is very rich in prepara- tions illustrating malformation and diseases of the teeth, there are examples of anchylosis of the teeth \Mth the jaw, occurring in rachitic subjects; and others exempli- fying the fragility of these organs in individuals of a similar constitution, and explaining their consequent liability to break in extraction. I tooth by several weeks, and indicate an increased | activity in the process of ossification and develop- ment, or what in common language is called j breeding the teeth. In such cases the symptoms subside in a few days, to recur again when the tooth approaches the surface of the gum. In the first period the pressure of corals and other hard j substances on the gum seems to be agreeable, by numbing the sensibility and dulling the pain. A better form than that of the ordinary coral is an ivory ring, as it obviates the danger of its being thrust into the eyes or nose. Rousseau, in his Emilius, objects to the use of hard substances for this purpose, and refers us to the instinct of the young of other animals, which leads them to ex- ercise their budding teeth, not on bone or stones, but on softer substances, on which they can make some impression. In accordance with this view a stick of marsh-mallows or of liquorice root, a piece of wax-candle or a crust of bread, have been re- commended instead of the coral; and in France they often dip them into honey or a sweet decoc- tion of barley, in order to render them more agree- able to the child, and more relaxant to the gums. In some parts of Germany we frequently see in- fants sucking a small bag containing a mixture of sugar and spices, which is given to them when- ever they are fretful or uneasy. It re-acts suffi- ciently on the gums, and certainly seems a very successful expedient for occupying the child and keeping it quiet: it thus saves the nurse some trouble; but the injury which the constant use of these sweet and stimulant ingredients must do the stomach, renders their employment very ob- jectionable. Gentle friction of the gums by the finger of the nurse is pleasing to the infant, and seems to have some effect in allaying irritation and altering the mode of the sensibility. Pain appears to be the chief cause of all the morbid sympathies accompanying dentition, and is attributable partly to pressure on the membra- nous sac and on the gum, and partly, or, as some think, principally, to the pressure made by the root of the tooth on the dental nerves. In feeble and delicate children dentition is usually, as we should naturally expect, more tedi- ous and difficult than in the healthy and robust; but to this there are numerous exceptions ; and it is certain that when disorder does occur in the latter, they suffer much more severely, and are more apt to be cut off suddenly by superinduced inflammatory affections, as was long ago remarked by Hippocrates. Puny infants, on the contrary, are more prone to a wasting diarrhoea and maras- mus ; and those reared in a crowded city gene- rally suffer much more than those who have been brought up in the healthy air of the country. In a word, the two extremes of debility and high health, or rather that appearance of it which is induced by over-feeding, are both exposed, and nearly in an equal degree, to danger;—the former from a low wasting fever and bowel complaints ; the latter from acute fever, determination of blood to the head, and convulsions. Those who have asserted that robust children always suffer most, have perhaps been mislead by external appear- ances, forgetting that every the slightest change DENTITION. 597 of condition in the fat and florid child will be more obvious and striking to the eye, than in one which was already pallid and thin. The management of infants during teething, when the process is going on in a favourable manner, is very simple, and rarely calls for the interference of the physician. The child should be much in the open air, and well exercised, and the bowels kept free. The employment of the cold-bath or cold sponging daily, followed by gen- tle friction over the surface of the body, is very useful; and all means should be taken to support the tone of the system at a just medium. The breast should be giv«»ii to it often, but not long at a time, and thus the attendant thirst will be quenched, and the gums ke;>t moist and relaxed, and their irritation soothed, without the stomach being overloaded. The health and diet of the nurse should at this period be particularly attend- ed to, and all stimulant food and drinks avoided. Dr. John Clarke, in his Commentaries on the Diseases of Children, ascribes most of the disor- ders which accompany dentition to over-feeding and consequent plethora; to improper kinds of food, which produce irritation ; and to keeping the head too warm. He asserts that coolness of the head, and washing it daily with cold water, ren- ders children much less liable to illness during this period. Spontaneous salivation and moderately lax bowels are always to be considered favourable, as they tend materially to diminish irritation; and when absent, their place should be supplied by gentle aperients, especially in the case of plethoric children, or those with cutaneous eruptions. [It has been a question, whether, during the irritation of teething, when the child is desirous of conveying everything to the mouth, hard sub- stances should be permitted to press upon the gums. It is a common custom to allow the child the use of a piece of coral, or of sealing-wax, or what is preferable — inasmuch as it cannot be forced into the mouth and injure the soft parts of that cavity—an ivory ring. Some of the French writers discard all such substances, but without much propriety. If the gums be very tender, the child will not use them ; and, if pressing the gums upon them should afford relief, there appears to be no good reason why their use should be forbidden, as the pressure cannot fail to aid the absorption of the gum. It has been suggested, as a good plan, to allow the child the use of a small wax candle, a stick of liquorice root, or a crust of bread. The first of these may be unob- jectionable ; but the liquorice root may load the stomach with mucilaginous saccharine matter, if allowed too freely; and the crust of bread may excite alarm, by the softened portions getting into the glottis, and producing symptoms of strangling. The physician, however, is not often consulted on these points; the whole matter being generally regulated by the parent or nurse. (See the writer's Practice of Medicine, 2d edit. i. 41.)] When d"ntition is difficult and tedious, the treatment is more complicated, and consists in alUying local irritation, moderating urgent symp- tomatic affections, and when protracted and pro- ductive of much exhaustion, in supporting the general strength. But, in order to treat of this part of our subject more satisfactorily, we shall divide the phenomena of difficult dentition into the idiopathic or local, and the sympathetic or secondary. These latter might again be divided either according to their nature, into spasmodic and inflammatory ; or according to the organ or | texture which they affect; as this latter subdivi- sion appears more conducive to accurate diagnosis, | we mean to adopt it Of the local symptoms, or those occurring in or | near the mouth, painful inflammation and swell- ing of the gum, which is hotter, of a deeper red than natural, and intolerant of the slightest pres- sure, are the most usual, and the cause of all the rest. There is often great determination of blood I to the head, the cheeks being red, hot, and swollen, the eyes irritable and watery, the salivation pro- fuse, and the salivary glands occasionally enlarged I and painful. Aphthae sometimes occupy the mouth and fauces, and abscesses have, in some rare cases, been observed at the root of the tongue. The symptomatic fever is often great, and is remarka- ble for its sudden rise and declension, intermitting and recurring frequently in the course of a few hours. The thirst is extreme, and the child is at one time restless and irritable, and at another heavy and oppressed. The sleep is broken, and the infant frequently awakens suddenly and in a fright from its short slumbers. The urinary se- cretion is usually much diminished, though cases do sometimes occur, as has been mentioned by Whytt, when it is increased, and in such the ac- companying symptoms will generally be found to be more of a nervous than an inflammatory char- acter. As all these symptoms are induced by the pain- ful tension of the gum, the most rational mode of attempting their relief is by freely lancing the swollen part. Of the practical utility and perfect safety of this operation, notwithstanding the pre- judices which exist against it in some other coun- tries, we have ample proof in its daily performance with impunity, and in the instant relief which it often affords to all the symptoms. To give it a chance of success it must be done effectually, and both the gum and the capsule of the tooth laid fairly open. An assistant holds the head of the infant firm, whilst the operator, with a gum lan- cet or a narrow bistoury having three-fourths of its blade guarded, separates the jaws, and keeping the tongue and cheek out of the way with the fingers of his left-hand, cuts down firmly in a longitudinal direction on the inflamed and swollen gum ; and if it be a double tooth which is coming forward, he should convert the incision into a crucial one. In Paris they often dissect out the flaps, but this seems to be. an unnecessary addi- tion to the pain of the operation. The slight bleeding which occurs is highly beneficial, acting as a local depletion, and thus conspiring to take off tension. The fears of an excessive or debili- tating loss of blood from this source, may be con- sidered, as to all practical purposes, unfounded and chimerical. We do not usually recommend the performance of this operation till the tooth be already so far advanced that we can be pretty sure of succeeding in laying open the capsule : for slight scarifications of the gum can afford no effec- tual or permanent relief. Cases may, however, occur, where even the temporary ease which su- 598 DENTITION perficial scarifications are capable of affording should not be renounced ; but here we must take care to explain to the child's friends the object of their performance, else the speedy return of the symptoms and the non-appearance of the expected tooth may tend to bring the operation of lancing the gums, or our own skill, into disrepute. The old apprehension that the scars which ensue, op- pose, by their hardness, the subsequent progress of the tooth, though repeated in one of the latest French works on the diseases of children, is quite groundless; for cicatrices, like all other new-form- ed parts, are, as Hunter long since pointed out, much more easily absorbed than the original struc- ture. Slight ulcerations of the gum have in some rare instances succeeded to the incisions; but this is a very unusual occurrence, and may be gene- rally prevented by taking care to have our lancets perfectly clean ; they are, besides, of very little consequence, as they readily heal under slightly astringent applications. Both Underwood and Ha- milton enumerate ulceration of the gums amongst the occasional effects of teething, and the former thinks they occur even more frequently in cases where lancing has not been performed. When the pain, determination of blood to the head, and fever, persist after the gums have been freely lanced, laxatives, mild diaphoretics, the warm bath, and slightly stimulating pediluvia must be employed, and if these be insufficient, one or two leeches should be applied behind the ears. When by the above means the fever has been in some degree reduced, the bowels continuing free, if the pain be still very severe, the cautious use of ano- dynes, as a drop or two of tincture of opium, or minute doses of hyoscyamus, may be tried. But perhaps as a general rule, seeing that infants are so very susceptible of the influence of narcotics, their external use, in the form of anodyne fric- tions to the spine, is preferable. When very rest- less at night, the infant should be frequently taken up and carried about in an airy room : by the cool air and the nearly erect posture, the feverishness will be alleviated, and the tendency of blood to the head counteracted. Such are the measures which modern expe- rience has found the most effectual in moderating the pains of dentition. Very different was the practice of our forefathers, who, misled probably by the fanciful doctrine of signatures, were in the habit of applying to the gums specific ointments made of the brains of hares, or of the combs of cocks, which, as old Hartman would have us be- lieve, " cause the production of teeth without difficulty and free from accidents." Whilst we smile at the credulity of former generations, we must not forget that the anodyne necklaces and other charms still in use in our own day are in no wise more trustworthy or less absurd. With regard to the affections of distant organs occurring during teething, we must not forget that they may originate as primary or idiopathic diseases at this period as well as at any other. Still, after making every allowance on this score, certain disorders manifest'themselves 60 much more frequently during this process, and often subside so rapidly on the appearance of a tooth, as to leave us no doubt with regard to their occa- sional connection with the business of dentition. Of the disorders which may be thus called into action by the irritation of teething, very formidable lists have been made out by authors. The follow- ing is a specimen of these, and of the confused manner in which symptoms and diseases are often jumbled together: vomiting, anorexia, diarrhoea, cholera, costiveness, increased or diminished urine, urethral or vaginal discharge, with painful mictu- rition ; dry cough, dyspnoea, catarrh, pneumonia, spasmodic affections of the face, limbs, glottis, &c.; insomnia, agitation and fright on awaking, epilepsy, somnolence, stertor, coma, transient palsy of the arms and legs; ophthalmia, hydro- cephalus, marasmus; eruptions, especially about the head and face, swellings of the hands and feet, enlargement of the cervical, femoral, and mesenteric glands, and other scrofulous affections. From this enumeration it appears that the chylopoietic and respiratory organs, the brain and nervous system, the skin and the lymphatics, are the chief seats of the sympathetic affections occa- sionally induced by dentition. I Of these secondary affections, those of the mu- cous membranes are the most frequent, and they may be either inflammatory or not Inflammation of the conjunctiva, of the mucous membrane of the air-passages and lungs, or of the stomach and intestines, will be characterized by the usual symptoms, and require the same kind of treatment as idiopathic inflammation of the same parts, though it will rarely be necessary to push it so far. Incision of the inflamed gums should always be premised, and will sometimes, without the em- ployment of almost any other measures, be follow- ed by the speedy resolution of the disease. Far the greater number, however, of these affections are not truly inflammatory, but depend : on a peculiar state of irritation kept up in these remote organs by sympathy with the inflamed gum. Such, usually, is the nature of the accom- panying cough, vomiting, or diarrhoea. When the vomiting and purging are not attended with pain on pressure, redness of the tongue, loss of appetite, or great oppression and fever, we have no reason to believe in the existence of inflamma- tion, either in the stomach or intestines. Such symptomatic vomiting may usually be restrained [ by diminishing the quantity or varying the quality j of the child's milk or other food; and if there be 1 evidence of excessive determination of blood to the head, by the application of one or two leeches behind the ears. Should it prove very obstinate, and debility, and loathing of food be induced by it, narcotic frictions and fomentations of the abdo- men, and a small blister applied for three or four hours to the epigastrium or to the upper part of the spine, may be requisite. In severe and protracted diarrhoea interfering with the sleep and nutrition, and accompanied by debility, emaciation, pallid skin, a dull eye, and [ sunken expression of countenance, in addition to some of the above measures, tonic and alterative aperients are called for, such as rhubarb combined with ipecacuanha or hydrargyrum cum cretS. Absorbents will be necessary if there be acidity in the primae viae, which is a frequent symptom in the derangement of the digestive organs in- duced by teething, and is evidenced by griping I and by green and sour-smelling stools. If the dis- DENTITION. 599 charges are of a bad quality, being fetid, blackish, or very pale, an occasional dose of calomel to modify the intestinal secretion should be exhibited. In very obstinate cases the cautious use of Dover's powder, opiates alone, or in combination with minute doses of calomel, and given at short in- tervals, or opiate enemata may be indispensable. But in the latter mode of exhibiting opium, espe- cially in the case of children, we must never forget that its action is sometimes, as has been pointed out by Dupuytren, even more energetic than when given by the mouth. The diet must be particularly attended to, the nurse changed if her milk seem to disagree, and the strength sup- ported by beef-tea, rice-milk, arrow-root, &c. In many of these cases, quinine in small doses will be found a very useful auxiliary. We are not advocates for the premature use of medicine in this affection: as on the one hand neglected diarrhoea is a frequent cause of death in dentition, and as on the other a lax state of the bowels has a great influence in moderating the dangers of this period, it requires a very nice discrimination on the part of the practitioner to know when to interfere. Perhaps no attempt should be made to check the intestinal secretion so long as the ap- petite, sleep, and strength continue unaffected. It is certain that bowel complaints, which would be thought very alarming at any other time, are often well borne when they depend merely on the irritation of teething. We should therefore, in most cases, content ourselves with watching their progress as long as they keep within the limits stated above. Vomiting and purging often co-exist, and in their combination frequently constitute a very formidable affection. M. Cruveilhier ha*s described, under the title Maladie gastro-intestinale des enfans avec desorganization gelatiniforme, a very violent and fatal disease of the stomach and intes- tines of this kind, which is characterized by ex- cessive thirst, urgent vomiting, and frequent, very fetid, green stools, like chopped spinach. After repeated vomiting the child becomes cold, and falls occasionally into a state approaching to syn- cope. The pulse is slow and irregular; the intel- lectual faculties continue clear to the end. The infant is extremely irritable and cries incessantly, except whilst being carried about in the nurse's arms. A state of drowsiness and oppression soon supervenes, the face assumes a cadaverous appear- ance, and the eyes are half closed and turned up. The coldness of the body, and especially of the extremities, goes on rapidly increasing, and in the course of twenty-four or forty-eight hours, a state of extreme prostration and fatal collapse are some- t mes induced. By a superficial observer this dis- ease might be mistaken for a cerebral affection, as there is somnolence, and screaming, with slow- ness and inequality of pulse in both ; but in the peculiar disorder under consideration the somno- lence is interrupted by the slightest touch, the sensibility of the skin is morbidly increased, the intellectual faculties are entire to the last moment, and the respiration is not unequal, as in disease of the brain. On dissection, the mucous mem- brane of the stomach, and generally that of the small and great intestines, is found in a state of softening, being reduced to a soft and disorganized pulp, but without any appearance indicative of inflammation. Cruveilhier's treatment consisted in confining the diet entirely to milk, and giving even that in the very smallest quantities, together with baths and fractional doses of opium admin- istered at short intervals, both by the mouth and in enemata. The chief causes of the disease seem to be improper food, premature weaning, and dentition. It may run on for many days, or even weeks, and when it proves fatal, terminates at last either by an acute attack or by gradual sinking. It is evidently closely allied to cholera morbus, and is in no degree an inflammatory affection. M. Guersent, physician to the Children's Hos- pital at Paris, has given a description of the above disease, differing in some respects from that of Cruveilhier's. He remarks that this peculiar com- bination of vomiting and purging occurs only in young infants from three or four months old to the end of the period of dentition, and is most common when they are getting the canine and double teeth. The diarrhoea is extremely abund- ant, and the stools are sometimes yellow, but of- tener green, like flocculi of confervae floating in a transparent serous fluid. Vomiting is soon super- added, first of a serous fluid, and at a later period of a porraceous matter. A dry cough and irreg- ular febrile exacerbations usually occur in this affection .- the prostration of strength and emacia- tion are extreme. Towards the close, slight con- vulsive motions are observed, chiefly about the face and eyes. The voice becomes excessively feeble, the features become relaxed, and the child sinks at length either in a state of agitation or of extreme exhaustion, whilst the consciousness to surrounding objects continues unimpaired to the last. There arc some varieties of the disease: thus the diarrhoea may precede the vomiting many days; or they may both commence nearly at the same moment, and the child then dies with symp- toms of cholera in the space of three or four days, or occasionally even within twenty-four hours. The affection sometimes, however, assumes a more chronic form, lasting thirty or forty days; but here there are frequent suspensions and renewals of the symptoms. On dissection, the mucous membrane of the stomach and intestines has usu- ally been found pale, colourless, and almost trans- parent, as if it had been macerated in water, and the mucous follicles are in their natural state. In some rare cases slight redness has been evi- dent in the coecum and colon, but this so seldom, that it could only be considered as a casual com- plication ; and the same may, according to Guer- sent, who is here at variance with Cruveilhier, be said of the softening of the mucous membrane of the stomach and intestines, which forms no essen- tial or constant part of the disease. The treat- ment which he has found to succeed best in this peculiar affection, as well as its morbid anatomy, tends to prove that it is much more nearly allied to cholera than to gastro-enteritis : this treatment consisted in the very lowest diet, mucilaginous drinks, emollient injections, fomentations and nar- cotic cataplasms. Leeches arc almost always use- less or injurious. As the disease advances, baths and the very cautious use of opiate enemata are proper; and when the prostration is ex- 600 DENTITION. treme, sinapisms and blisters should be applied to the limbs, nucha, or abdomen. Tonics and stim- ulants have usually seemed to do harm. In the acute or cholera form it mostly proves fatal in spite of all kinds of treatment It is here from opiates internally that we can alone expect any benefit. Dr. Parrish, of Philadelphia, has described a spasmodic affection of the intestines, or a species of flatulent colic, which he thinks is often depend- ent on the irritation of teething. The belly swells up rapidly and becomes extremely tender to the touch, the child cries much, the muscles of the face and limbs are spasmodically contracted, and the stools are suspended. The only thing which gives relief is the expulsion of flatus, and the consequent reduction of the tympanitic state. The appropriate remedies, after lancing the gums, seem to be draughts or enemata, containing a few grains of assafcetida, and two or three drops of laudanum, friction of the abdomen and spine with an anodyne liniment, and the induction of a free state of the bowels by some gentle aperient, or a soap suppository. Mr. Parrish has recommended, as an immediate mode of relief, the extraction of the air from the rectum by means of a syringe. Having already alluded to disorders of the chest, we shall here only add that a susceptibility to catarrhal, and even peripneumonic affections, seems to be occasionally induced by teething. When the presence of inflammation is indicated by fits of coughing so painful as to make the child cry, and by soreness of the chest, dyspnoea, anorexia, and feverishness, after lancing the gums, repeated purgatives, emetics, and diaphoretics will often afford much relief; but in severe cases leeches and blisters must never be omitted. The dry nervous cough of irritation is, how- ever, by far the most frequent species, and may occasionally be much alleviated by anodyne fric- tions of the spine and abdomen, though it often resists all treatment till after the tooth is cut, and then ceases spontaneously. Cough at this period seems sometimes to depend on an intermediate derangement of the digestive organs, as is indi- cated by the state of the tongue, tension of the abdomen, unnatural stools, and the absence of fever : here emetics and purgatives are the appro- priate remedies. Affections of the brain and nervous system may occur in every degree from a slight and passing determination of blood to those organs, up to the most violent irritation, congestion, or even inflam- mation. The pain in the gums keeps the nervous system in a state of constant excitement, which is favourable to the development of spasmodic affections. When there exists considerable plethora and drowsiness, the use of purgatives and leeches, with blisters to the nape of the neck, is indispen- sable. On the other hand, a state of insomnia is occasionally induced ; or the sleep is much in- terrupted, and the infant often awakes with a start, frightened and crying. This should never be overlooked by the physician, as it indicates a condition in which the occurrence of epilepsy or convulsions is by no means improbable. It seems sometimes to depend on cerebral congestion, and sometimes on derangement of the digestive organs, though occasionally it is purely nervous; and ac- cording to whichever of these may be its cause, it will require the use either of leeches and purga- tives, or of antispasmodics and warm baths. Where much fever accompanies dentition, con- vulsions often occur, especially if the bowels be in a constipated state. Neither feeble and irritable, nor large and fine infants are exempt from their attacks: but the latter are the most apt to be cut off' suddenly by them. It is with the protrusion of the anterior molars, or of the canine teeth, that they most frequently come on; and they are oc- casionally preceded by grinding of the teeth, trembling of the lips, and other premonitory symp- toms. They are not always so dangerous as is commonly imagined, and are least so when con- fined to spasmodic motions of the eyes, face, and arms. But if, on the other hand, the fits are very general and violent, and succeed each other rapidly, they are then always very alarming. They occa- sionally terminate in apoplexy or paralysis. As very formidable convulsions have been known to cease immediately on the gums being lanced, this operation should never be neglected where they appear swollen and painful. Tepid baths, leeches, purgatives, narcotics, and antispasmodics, are se- verally useful in different states of the system. Thus, if pain be the predominant symptom, we should avail ourselves of the soothing influence of tepid baths; if the sleep be lost, the cautious use of narcotics will be justifiable, provided there be no fever; otherwise, and especially if the child be plethoric, purgatives and leeches must be pre- mised. In weakly children, assafcetida and some other medicines of the antispasmodic class have been occasionally found useful. Sprinkling cold water in the child's face while in the bath will often cut short the fit; and when the recurrence of the disease is very frequent, an issue at the back of the neck, or the production of an artificial eruption, is to be recommended. (See Convul- sions, Infantile.) Underwood speaks of a transient palsy of the arms and legs occurring as each tooth is coming out, and which does not re- quire any particular treatment beyond attention to the gums and to the bowels. The paralysis after convulsions is often permanent and hopeless: leeches and counter-irritation to the spine should, however, have a trial in such cases. Of the convulsive affections occurring during dentition, one of the most formidable is spasm of the glottis, sometimes, but improperly, termed spasmodic or chronic croup. Dr. John Clarke has described it under the title of " a peculiar Convulsion of Infant Children,-" and it has also been noticed by Dr. Hamilton, of Edinburgh, and Dr. Cheyne, of Dublin. Dr. Monro has alluded to it where he speaks of a peculiar species of hydrocephalus, attended with spasm of the glottis. It has been written on by Mr. Pretty, in the Medical and Physical Journal, under the name of cerebral croup, and has been described, in France, by M. Guersent, under the title Pseudo- croup nerveux, and still better by Gardien, under that of Spasme du thorax et de la glotte,- and by Richter, Raimann, Schmalz, Wichmann, &c. in Germany. But the latest, and much the 'most satisfactory account of this disease is that by Dr. Marsh, in his paper in the Dublin Hospital Re- DENTITION. —DERIVATION. 601 ports, vol. v. to which, and also to the article Glottis, Spasm of, in the present work, the reader is referred. A peculiar swelling of the hands and feet has been mentioned by Underwood as an occasional symptom of painful dentition. It was considered by him as in itself, if not decidedly beneficial, like a slight diarrhoea, at least unimportant, as he found it to cease spontaneously when the tooth came up. If any feverishness co-existed, he at- tributed it not so much to those tumours, as to the casual coincidence of derangement in the bowels or some other organ. Dr. Kellie. of Leith, who has described this singular affection more at large, asserts that though it be sometimes thus slight and transient, yet in many cases it has appeared to constitute a part of a disease of a more striking and serious nature. The swelling, which is situated on the back of the hand and on the dorsum of the foot, has a considerable degree of roundness and elevation, such as might be produced by a blow. It seems to arise suddenly, and is of a mottled, somewhat Uvid, or purplish colour, feeling rather cold, and exhibiting no sign of inflammation or increased sensibility. It is firm, and does not pit on pres- sure. It will occasionally continue for weeks, gradually becoming softer or assuming somewhat of a leucophlegmatic hue, to which occasionally, but very rarely, oedema of the whole limb has been known to supervene. Usually, however, it disappears more suddenly, without passing into the leucophlegmatic stage. It is generally con- nected with a symptom of a more formidable character than itself, viz., the spastic contraction of the flexors of the thumb and toes. The thumb is rigidly contracted and permanently bent down- wards, and laid flat upon the palm of the hand; and in like manner the toes are bent down to the plantar aspect of the foot. The carpus is also sometimes drawn down by its flexors, so as to in- crease the sphericity of the metacarpal bones. The child is peevish and restless, but does not seem to suffer much pain in the affected parts. In some cases only there is pyrexia towards the evening; the bowels are commonly torpid, and the stools procured by laxatives are fetid, clayey, green, sour, and slimy. Its duration is from a few days to several weeks, and its termination usually favourable. General convulsions have, however, sometimes supervened ; in one of Dr. Kellie's cases fever made its appearance, and two others died with what Dr. Armstrong calls symp- toms of " hectic teething." It is a disease of the epoch of dentition, and as the symptoms have oc- casionally ceased immediately after the cutting of a tooth, we may conclude that teething is, at times at least, its exciting cause. The treatment recommended by Dr. Kellie consists in scarifying the gums, removing plethora if it exist, restrain- ing vascular excitement and local determination, and regulating the alvine discharges. Of the cutaneous eruptions connected with den- tition little need be said, as they seem, by their derivative action, like a lax state of the bowels, to be rather useful than otherwise. The principal varieties are, an erythematous efflorescence behind the ears (intertrigo) ; crusta lactea ; the different varieties of strophulus (the red gum or tooth-rash Voi. I. —76 3 a of the vulgar); small phlyctenae, like those of a burn, and evanescent red spots appearing upon the face and other parts. But as most of these may occur also quite independently of dentition, we can be certain of the connexion in those cases only when they make their appearance, or undergo an exacerbation, just before the cutting of a tooth, and become milder or disappear after it Should they run to such an extent as to become trouble- some, laxatives are the best means of keeping them down. During their existence exposure to cold should always be avoided. Disease of the lymphatic system is an occa- sional result of the debility often induced by teething, and is manifested in the enlargement of the cervical, inguinal, and mesenteric glands, &c. In these, as in all other scrofulous affections, our chief attention should be turned towards the im- provement of the general health by good air, nu- tritive food, regular exercise, attention to the diges- tive organs, and other measures to which we have alluded in a preceding paragraph. The Second Dentition. — The milk-teeth generally begin to fall out about the seventh year, or somewhat earlier, and are replaced in the course of five or six years by the permanent teeth, which usually come up with little or no pain. Cases do, however, occasionally occur in which there is considerable local irritation, and consequent en- largement of the glands about the jaw and neck, ophthalmia, cutaneous eruptions, &c. The wis- dom-teeth, which are cut about the twenty-seventh year, or occasionally much later, are often produc- tive of considerable uneasiness and swelling. The pain being sometimes periodically intermittent, has been mistaken for an aguish or rheumatic affection, and treated with bark and similar medi- cines. Cases are mentioned where, from the im- perfect development of the jaw, there has not been room enough for the dentes sapiential to como easily forward ; and hence much pain and swell- ing of the face, together with violent headach, in- flammation of the eyes, pain in the ear, and ab- scess near the angle of the jaw, have resulted. Free incision of the gum, or even extraction of a tooth, may, in some of these cases, be necessary, along with leeches, fomentations, and poultices to the external swelling. The second set of teeth occasionally come up before the first have fallen out, and we have then the singular appearance of a double row of teeth : on the other hand, there are instances on record of individuals who did not begin to get the second set till they were forty or fifty years of age. The cases in which veiy old persons have cut a third set of teeth (See Ed. Med. Comment, vol. iii.) are so extremely rare, that we only allude to them because their development has been sometimes ac- companied with excruciating pain and other cir- cumstances, which might be extremely puzzling to the practitioner if not aware of the possibility of such an occurrence. W. B. Joy. DERIVATION (from derivare). This term may be received in two acceptations : it may ap- ply to an effect produced on any morbid condition of parts by an artificial irritation or determination elsewhere, which removes or diminishes the pri- mary oiie ; or to the removal or diminution of a 602 DERIVATION. morbid condition, consequent on the occurrence of a new irritation or excitation of action not ar- tificially produced. Thus when a blister is ap- plied in a case of pneumonia, with relief of the pulmonary disease, we have an example of the first acceptation ; and when a disease of the lungs subsides on the occurrence of a cutaneous erup- tion, or of a diarrhoea, we have an instance of the second. In either case the principal pathological phenomenon is the change of the seat of irritation or excitement. The term revulsion is one better adapted to ex- press this phenomenon, but it matters little which phrase we adopt. The older authors entered into many arguments respecting the difference between revulsion and derivation, but as their ideas on these subjects were founded on false physiological views, we shall pass them by here. The circumstances under which derivation, as taken in its first acceptation, is observed, may be thus enumerated. First, the application of agents to the two great surfaces of relation, namely, the skin and mucous membranes, calculated to irritate or merely in- crease the normal action of these tissues; and secondly, the use of stimulants calculated to ex- cite the secretions of various of the parenchyma- tous organs. Under these heads may be enume- rated all the irritating applications which we make to the skin, such as cantharides, ammonia, tartar emetic, &c, and also the use of friction and heat When we employ purgatives to cure a dropsy, or a disease of the skin or of parenchy- matous organs, when we use diaphoretics to re- lieve a mucous inflammation, or diuretics to re- move serous effusions, we act on the derivative or revulsive system, and the remedies are in all cases derivatives or revulsives. In some of these cases, we cure or alleviate the original disease by the production of a new inflammation in the part act- ed on, as in the case of blistering; in others, the part acted on is not made the seat of a new in- flammation, but its normal secretion is excited and increased, as in the case of warm bathing pro- ducing diaphoresis. The second example of artificial derivation is the production of irritation in tissues deeper seated than the skin, but still exterior to the vis- cera. Of this, the use of setons and issues is an example. But, as we have already shown, derivation or revulsion is often found to occur independently of any artificial excitation, and the consideration of this subject comes to be of the highest interest in medicine. As, however, it is more immediately connected with metastasis, we shall in this place merely sketch the leading physiological facts con- nected with this species of derivation. One of the most interesting of these is, that this revulsion often occurs between analogous tissues; thus, in cases of inflammation of the synovial membranes, the sudden subsidence of the disease is commonly followed by inflammation of some of the serous membranes, such as the pericardium, peritoneum, pleura, or arachnoid. Again, a patient has diar- rhoea ; this suddenly subsides and is succeeded by violent bronchitis ; he has a disease of the skin, which is repressed, and the mucous membranes become engaged, or vice versa. But this rule is by no means so general as to form a law in pa- thology, for we find very many instances of ex- ception ; for example, the occurrence of ascites after suppression of the perspiration, hemorrhage from the kidneys after the desquamation of mea- sles ; the alternation of catarrh and hemiplegia; of gout and gastro-enteritis, or bronchitis; of mania and oedema of the lower extremities. We shall not here examine the relation of cause and effect in these examples of conversion of dis- ease ; it may suffice to remark, that in some cases the subsequent or secondary disease appears to arise from the cause so well illustrated by Brous- sais, namely, the predominance of the sympathetic over the primary irritation ; while in others it seems to result from a morbid condition of the whole system, consequent on the subsidence or removal of some local irritation, which, from its chronic duration, has apparently become neces- sary for the proper balance of the constitution. Two modes of revulsion are used in medicine. In the first, we endeavour to change the seat of irritation or excitement from the viscera to the surface; in the second, we change it from one viscus to another. The first may be called the exterior or peripheral revulsion; the second, the interior or visceral. To the first of these we shall in this article principally direct our attention. The modus operandi and therapeutic applica- tion of the exterior derivatives are questions of great interest in medicine. In some cases the application of a blister to the surface is followed by great relief of the internal disease, while in others the reverse occurs. To determine the cases in which the favourable or unfavourable results may be reasonably expected, comes to be a great desideratum. Here experience is our chief guide. It has been long known that blisters will relieve local inflammation of the internal parts under three circumstances; first, where the disease is of the acute character, but modified in its intensity by active antiphlogistic measures; secondly, where it is acute, as respects the time, but occur- ring in cases where the powers of life are low, as in typhoid inflammations ; and, lastly, in chronic diseases. In all these cases, the activity of the capillary circulation in the diseased part is weak, and revulsion taking place with ease, a rapid re- moval of the local disease is often the effect of our treatment. On the injurious effects of exter- nal revulsives in acute inflammations, before de- pletion is used, most authors are agreed. Rostan, in his Clinical Medicine, says, " Revulsions are generally contra-indicated in the early stage ot acute diseases when there is fever and the subject is young and strong." The same author, in an- other place, says that although a derivative effect is often obtained, yet that in many cases excita- tion will follow the use of revulsives, and an effect directly contrary to that expected will be produc- ed. Mr. Porter, in his " Surgical Observations on the Diseases of the Larynx and Trachea," expresses himself strongly against the use of blis- ters in acute laryngitis, particularly when applied to the neighbourhood of the part. He says, they cannot be resorted to at an early period without considerable risk of doing mischief. A case is related, where, in acute pneumonia, the applica- tion of a blister was followed by an aggravation DERIVATION. 603 of the symptoms and death. On dissection a portion of the surface of the lung, exactly corre- sponding to the size and shape of the blister, was found in a more advanced stage of inflammation than the remaining pulmonary tissue. Many other authors might be quoted to the same effect. Our own experience is decidedly in favour of these views. We have often seen a distinct exa- cerbation follow the application of a blister in the acute pneumonia, bronchitis, or gastro-enteritis of children, in cases where bloodletting was not used ; and many medical friends have informed us of similar occurrences in their own practice. Even in a few chronic cases we have observed the same effect where local bleeding has not been pre- mised. We must, then, admit that external derivatives have two modes of action ; the one derivative, the other directly stimulant on the diseased part. We find them, as we stated before, generally useful in three sets of cases, namely, acute inflammations where general and local bloodletting has been premised, typhoid inflammations, and chronic dis- eases : and it becomes probable that a part at least of their utility is owing to the direct stimulus conveyed to the capillaries of the diseased tissue. A state of these vessels, analogous to Andrei's asthenic hyperxmia, in all probability exists, and we know that stimulation is often the best mode of removing this morbid condition. This will account for the injurious effects of external revul- sives in acute cases before depletion has been used, and is not inconsistent with their good effects in cases of a different description. They are all es- sentially stimulants. If the irritability of the sys- tem is great, an increase of fever will be the result of the sympathetic irritation of a blister, and in this way the local inflammation will be aggravated. Whether the increase of the local disease be always owing to this cause, or whether it may occur without the intervention of sympathetic fever, are questions of difficulty, but happily not of great practical importance. We often find, in cases of intense irritation of internal organs, that blisters will not vesicate the skin, but that, as soon as the disease has been modified, they will produce their usual effect. Can this be explained by supposing, that in con- sequence of the intense inward determination, the surface has lost a portion of ite vitality ? In such cases, the vesication of the surface is often not the cause, but the consequence of the diminution of diseased action. The means generally employed to produce ex- ternal revulsions are the application of blisters, sinapisms, or the tartar emetic ointment; and the use of setons, issues, the moxa, heat, and friction. In this country the most common mode is the application of blisters, either immediately over the diseased organ, or at some distance from it Un- pleasant consequences often follow even this sim- ple proceeding; of which the principal are the infliction of great pain, the production of a too violent inflammation, and the occurrence of stran- gury. All these bad effects appear frequently to arise from the practice which commonly prevails of allowing the blister to remain on for twelve or even twenty-four hours; a mode of proceeding totally useless, and constantly injurious. , Dr. Leahy, the learned Professor of the Prac- tice of Medicine in the School of Physic in Ire- land, has long inveighed against this practice. His mode is to remove the blister as soon as de- cided pain is produced, although the part be no* vesicated. Simple dressings are then applied ; and free vesication subsequently occurs; and in the majority of cases none of the distressing effects alluded to are produced. We can speak from our own experience of the superior efficacy of this mode, and feel strongly disposed to believe that were it more constantly pursued, we would see fewer cases of the aggravation of internal disease j from the use of blisters. These views are also much insisted on by M. Bretonneau, in his Traite de la Diphtherite. His mode of using blisters is peculiarly elegant, being founded on the experiments of Robiquet, which show that the vesicating principle is soluble in fatty substances. A piece of extremely thin paper is inserted between the blister and skin, through which of course the oily solution penetrates. Many of the inconveniences of the common mode of blistering are avoided, such as tha long-con- tinued irritation that portions of the cantharides produce by sticking to the part; the unsightly marks which blisters leave, &c.: and M. Breton- neau states that during six years' practice in his hospital, there did not occur a single case of ischu- ria after blistering performed in this way. Some practitioners, particularly on the Conti- nent, prefer applying blisters always at some dis- tance from the seat of disease ; in this way, ac- cording to their opinion, avoiding the danger of direct stimulation. Facts are still wanting to enable us finally to determine on the relative merits of these two modes of proceeding; but if the use of a blister over a part affected with acute inflammation is avoided until its capillary irrita- tion has been modified by antiphlogistic treat- ment, we believe that the practice will generally be found safe. The use of the tartar emetic ointment, as re- commended by Jenner, has now become very common. In some cases, however, it is produc- tive of great distress, in consequence of the forma- tion of large and angry pustules ; a circumstance in most cases arising from the use of too great a quantity of the salt in forming the ointment A drachm to the ounce of lard is the usual propor- tion ; but if we employ a diminished quantity, the remedy will act much better, and frequently with little or no distress to the patient. From a scruple to half a drachm of the salt, finely pul- verised, is generally sufficient; and in this way an extensive eruption of minute pustules will be produced, from which we have never seen any un- pleasant consequences to follow. An extraordi- nary effect of this mode of counter-irritation has been several times observed, namely, the super- vention of violent irritation about the parts of generation. At first it was supposed that the ir- ritating substance was directly conveyed to the parts by means of the patient's hands; but this opinion is untenable, as the eruption has occurred in cases where the greatest caution was used to prevent any direct conveyance of the ointment to the genitals. This circumstance is noted by Dr. Mackintosh, in his Practice of Physic; and both 604 DERIVATION. Dr. Graves and the writer of this article have had frequent opportunities of observing it in the Meath Hospital. In a case which occurred in private practice, the inflammation about the genitals in a young female was so severe as to threaten morti- fication. Another unpleasant result of this mode of counter-irritation is the occurrence of violent and obstinate vomiting, particularly where the ointment has been rubbed over the epigastric re- gion. We shall now proceed to consider the use of external revulsion in cases of visceral disease. Authors appear to agree as to the impropriety of using revulsives in cases of disease of the brain when it is acute, and particularly where bloodlet- ting has not been premised ; thus fully bearing out the doctrine which we have endeavoured to support in this article. In diseases of the brain and spinal marrow, all the different modes of revulsion have been prac- tised with great success. Indeed, with the excep- tion of the first stage of acute irritations, it may be said that revulsives are of the highest utility in all cerebral diseases, whether functional or organic: where coma supervenes, and in chronic affections, the best results often follow this practice. Thus in all the forms of paralysis depending on disease of the brain and spinal marrow, the various revulsives have long been recognized as among our best remedies ; and they may be often em- ployed as prophylactics, as in ca-es where an apo- plectic disposition decidedly exists, and where the life of the patient may be prolonged by the timely use of a seton in the neck. Dr. Jenner, in his letter on the influence of artificial eruptions, speaks in the highest terms of the utility of the tartar emetic ointment in the cure of insanity, declaring that in.all his cases (eighteen in number) this treatment succeeded in removing the disease. Dr. Burrows, however, is by no means so sanguine ; but states that in cases where insanity has ensued on the subsidence of a cutaneous eruption, or is connected with gastric irritation, this treatment will ameliorate the symp- toms. He prefers the use of the tartar emetic ointment to that of blisters. In Lalleinand's " Lettres sur l'Encephale," a case is recorded highly illustrative of the effects of powerful revulsion under the most unfavourable circumstance. A patient, upwards of sixty years of age, became affected with symptoms of ence- phalitis, in consequence of an injury of the head. The prominent symptoms were stupor, paralysis with convulsions of the right arm, embarrassment of speech, and loss of memory. The circum- stance of the injury of the head being unknown to his medical attendants, the case was considered as an example of idiopathic fever, until the tenth day, when the patient wa.s seen by M. Lallemand for the first time. The patient had then frequent and long-continued fainting fits; the limbs on the right side were contracted, with complete paralysis of sensation ; the eyelids closed, the eyes diver- gent and insensible to light; there was complete loss of hearing and intelligence; the body was covered with a cold sweat; the respiration frequent and stertorous ; and the pulse imperceptible. In this desperate state, Lallemand applied boiling water to the legs of the patient The first appli- cation produced a sudden motion of the whole body ; the left arm was agitated, the eyelids were raised, and the pulse became perceptible in the arm. In the course of half an hour the boiling water was applied to the thighs with still more remarkable effects : the face became red, and the pulse full and frequent. Ice was now applied to the head, and in two hours the sensibility was so so much restored that the patient frequently at- tempted to remove the cold application. Under this treatment, with the occasional application of a few leeches to the head, the patient was nearly restored in the course of eight days ; and in two months all paralysis had disappeared. The eschars produced by the boiling water were very deep, and suppurated abundantly, seven weeks elapsing before cicatrization took place. Dr. Mackintosh, in his Practice of Physic, details a case of severe cerebral affection in fever, where the best results followed a similar practice. In this case, however, neither paralysis nor coma had taken place. In the employment of revulsives in diseases of the brain, it appears most proper to select for the place of stimulation some part remote from the cranium. In this way the action of the revulsive can be powerfully assisted by the application of cold to the head, as by the use of ice, or, what is still better, the cold affusion, used hi the manner directed by Dr. Abercrombie. We may here notice the practice of counter- irritation along the spinal column, as proposed by Mr. Teale for the cure of hysteric affections; and which, according to him, has been followed by the best effects. It would appear, however, that as yet a sufficient number of observations has not been made to establish the pathological views on which this practice is founded. Doubtless, cases of spinal irritation do occur where the use of re- vulsion may be followed by the best results. In veterinary practice we have known good effects obtiined, in cases of tetanus, by the use of severe counter-irritation along the spinal column. In diseases of the respiratory organs, whether of the mucous membrane, parenchyma, or serous investment, revulsions have long been employed by physicians. The same principles which guide us in the use of revulsives in diseases of the brain are found to apply here :—improper in the acute stage, and even dangerous when the irritation has not been reduced by antiphlogistic measures, they are found generally of the highest utility in cases where the lancet has been used, and where the inflammation is of an asthenic or chronic character. In simple acute laryngitis, the best authors agree as to the impropriety of using blisters to the ante- rior portion of the neck. Guersent and Porter express themselves most strongly on this subject; the former, however, admitting that they may be useful in the asthenic croup ,- but he prefers em- ploying them at a distance from the affected part. Indeed, there are few diseases where so much caution should be used in any mode of treatment which would have a chance of increasing irrita- tion ; as we know that a momentary spasm of the glottis may suddenly extinguish life. In an irri- table patient, then, we must be extremely cautious in the employment of the revulsive mode. But in chronic laryngitis we find the best effects from counter-irritation in the neighbourhood of the part; DERIVATION. 605 repeated blistering, frictions with the tartar emetic ointment, and the use of the seton, being among our most successful modes of treatment in this obstinate disease. The good effects of severe counter-irritation in a case of chronic laryngitis of long standing, and which threatened the life of the patient/were strikingly exemplified some time ago in the Meath Hospital. The symptoms were extremely urgent, and were not alleviated by local bleeding. Two blisters, of about two inches wide and five in length, were applied along the course of the sterno-mastoid muscles, and the vesicated surface sprinkled with finely powdered tartar emetic. A most severe counter-irritation was thus produced ; the patient suffered extremely ; but the laryngitis was completely removed, and we believe the cure was permanent. In diseases of the lungs we find the same gene- ral principles equally to apply. We have seen many instances where the symptoms of acute pneumonia or pleuritis were clearly aggravated by the empirical use of blisters; but in the second state of acute bronchitis, in most of the forms of chronic catarrh, in hooping-cough, in hepatiza- tions, or passive congestions of the lung, and in the advanced stages of pleurisy, the revulsive practice is almost always followed by the best effects. The utility of the same practice in cases of chronic phthisis is so well known that we need not comment on it here. One of the most distressing circumstances in the progress of a case of hypertrophy of the heart, is the occasional increase of palpitations and pre- cordial distress: this is frequently relieved by the application of a blister; a circumstance which, combined with our knowledge of the efficacy of local bleeding in similar cases, adds greatly to the probable correctness of Andral's opinion, that in many such cases the cause of these symptoms is an irritation of the internal membrane of the heart In the examination of the effect of external re- vulsion in diseases of the digestive system, we must consider its employment in affections of the mucous and serous membranes. Broussais, in his Phlegmasies Chroniques, endeavours to esta- blish that in inflammations of the mucous mem- brane, both acute and chronic, such practice is always improper, and that those cases of altered function which are relieved by vesication of the surface, are not in reality examples of inflamma- tion of the mucous membrane. This assertion, however, appears too general; both analogy and experience lead to the conclusion that in acute gastro-enteritis the use of revulsives to the surface will be probably followed by bad consequences, but this is far from applying to the chronic affec- tions, where we know that this practice is con- stantly productive of the best effects. In schir- rhus of the stomach, in chronic diarrhoea, or dysentery, in tabes mesenterica, the great utility of external revulsives has long been established; so that, as far as the affections of the gastro-intes- tinal mucous membrane are concerned, the gene- ral principle which we have been endeavouring to establish is also borne out. In point of fact, Broussais does not. seem to be sufficiently aware of the utility of stimulation in the internal as well as the external chronic inflammations. 3a* The same conclusions are to be drawn in the case of peritonitis. In the violent acute disease, and particularly before general and local bleeding has been freely premised, a blister often aggra- vates the symptoms; but in the chronic and as- thenic forms of the disease, as in the low puerpe- ral peritonitis described by Dr. Cusack and Dr. Gooch, it is found that blistering the abdomen is often followed by the happiest results. We are indebted to Mr. Crampton for the par- ticulars of a remarkable case of chronic obdomi- nal disease, where a powerful and extensive re- vulsion was followed by the greatest relief of symptoms. A lady, who had laboured under ovarian disease, with severe symptoms of chronic inflammation of the mucous membrane of the in- testines, as evinced by diarrhoea, bloody stools, tenderness of the abdomen, and emaciation, was severely burned in consequence of her clothes taking fire; the neck, arms, and throat were the seats of the injury. On recovering from this ac- cident, the greatest improvement became mani- fest in her general health ; the bowels became re- gular, nutrition went on, the ovarian enlargement subsided greatly, and the patient has since enjoyed a state of good health which could never have been anticipated. For information on the employment of revul- sives in diseases of the urinary organs, and in affections of the generative system, we beg to refer to the articles on these subjects. We shall merely remark that many practitioners avoid the applica- tion of a blister to the loins in acute irritations of the kidney, such as nephritis or renal calculus, fearing that strangury would be certainly pro- duced. We believe that this fear is quite un- founded, and that the application of a blister to the loins may be constantly had recourse to with the best effect in these cases. There is no evi- dence to show that strangury is more liable to be produced by a blister to the loins than to any other part; but it is almost certain that in the majority of cases the strangury is owing to the mismanagement of the blister. The last class of affections in which we shall examine the utility of revulsives is that of fevers. Louis has investigated this subject with his usual precision, by comparing the effects of blisters in cases of typhoid fever which have proved fatal, and in those where recovery took place. In the first class, he found that the mean duration of the dis- ease was not altered by the practice; that no effect, either upon the temperature of the body, or the state of the circulation, could be connected with the action of the blister; that in two-thirds of the cases the cerebral functions underwent no alteration; and that, in the remaining third but a very small proportion presented alleviation of symptoms. The examination of the digestive functions showed the same results, so that he con- cludes that in his cases the action of blisters pro- duced no effect, either on the duration of the dis- ease or the progress of its symptoms. In those cases where recovery took place, he concludes that blisters had no appreciable effect on the dis- ease, and that they perhaps but slightly retarded the convalescence: so that, in connecting these facts with the inconvenience of blisters, he holds 606 DERIVATION —DIABETES. that they should be banished from the treatment of typhoid fever. It is to be remarked, however, that in these cases the blisters were applied, not over the splanchnic cavities, but to the extremities; the conclusions therefore only apply to this particular mode, and afford no reason for banishing the use of blisters from the treatment of typhoid fever. We know, indeed, from experience, that in cer- tain cases their utility is most remarkable. In the majority of cases of fever the attention of the phy- sician is principally directed to remove inflamma- tion or congestions in some of the great cavities, and revulsion is often the only mode left to him of accomplishing his object Thus in certain cases of coma occurring at an advanced stage of the disease, the greatest advantage is derived from the application of a blister to the head. In ca- tarrhal fever, when copious secretion sets in, and the powers of life are low, we have found, in the Meath Hospital, the most striking advantage from free blistering on the chest, and have never seen any unpleasant result. So, also, where pneumo- nia occurs in the course of a typhoid fever, the application of a blister, after depletory measures have been used, or where the skin is cool and the powers of re-action are slight, has been frequently successful in ameliorating or removing the dis- ease. Our experience in the Meath Hospital leads us to the conclusion that, as far as the utility of blisters in fever is concerned, we may use them for the relief of the secondary inflammations which occur, with great benefit; always, how- ever, acting on the principles which we have maintained in this article. [See the article Coun- ter-Irhitation for much information on this su •* c '-' William Stokes. DERIVATIVES. See Derivation. DIABETES.—Some of the earlier writers on medicine have given different names to the dis- ease which forms the subject of the present arti- cle. Thus it has been styled diarrhoea urinosa, hydrops ad matulam, hyderus, dipsacus, morbus sitibundus, fluxus urinx, nimia urinx profusio, polyuria. Owing to the excessive secretion and frequent evacuation of urine in this affection, it has also been named diabetes, from the Greek word iia/laivto, which signifies to pass through : and from the circumstance of the urine having generally a smell of honey, and a sweetish taste, the adjective melli- tus has been employed to denote this character. M. Renauldin, in an able article on diabetes in the Dictionnaire des Sciences Medicales, and after- wards Dr. Prout, insist upon defining diabetes to be " a disease in which a saccharine state of the urine is the characteristic symptom," although the etymological import of the word extends to any affection accompanied with an immoderate dis- charge of the urinary secretion. It is not the best losric, however, to found a definition upon an hypothesis; and as there are several instances on record of patients dying under all the symptoms of diabetes, yet without the slightest indication of sugar in the urine, we cannot fairly dispose of these by assuming its presence in the latent state; for it may be latent in the most incidental case of hysterical enuresis, and then how could Drs. Renauldin and Prout refuse the name of diabetes to this fortuitous symptom ? We make no un- fair extension of their hypothesis ; and to speak truth, chemists have as yet discovered no good test of either sugar or urea when in small quan- tities, nor, were they perfect, ought medical men to take their results as defining disease. Dia- betes, like every other malady, must not be de- fined by symptom a or symptom b, but by the aggregate and concatenation of the leading symp- toms. Of these, immoderate excretion of urine and cachectic emaciation seem much more cha- racteristic than sweetness, however general, and which it must be allowed is at times undistin- guishable. All the modes of analysis hitherto devised for indicating the vegetable and animal oxides are extremely imperfect, especially when these are intermingled with other oxides ; and the most delicate of them seem to consist, not in de- monstrating the presence of these oxides them- selves, but in generating new bodies, which are supposed to result from the re-union of the pri- mary elements into which the former had been supposed to be reduced by their operation. In every genuine case of diabetes, however, Dr. Prout contends that a careful analysis of the urine will detect more or less saccharine matter, even when the sensible qualities of this fluid fail to point out the least saccharine impregnation; for, as Dr. Watt has observed, sugar may be pre- sent, but so covered with other substances that it cannot be at all detected by the taste. Hippocrates seems to have been altogether ig- norant of this affection, for we find no allusion to it in any of his writings; but Celsus, Galen, Aretaeus, and Alexander Trallianus, have left us histories of diabetes. The description of it given by Aretaeus is particularly clear and minute. These writers, however, looked upon the disease simply as an increased flow of urine, and as pro- ceeding from renal irritation. Galen thought that this affection bore the same relation to the kidneys and bladder as the lientary does to the stomach and intestines. Aretseus considered it a colliqua- tion of the flesh and limbs into urine. He has observed, " that it has the usual urinary course, namely, the kidneys and bladder, for the patients never cease voiding their urine, but as from the openings of the water-ducts, the stream is perpe- tual." Trallianus adopted much the same view of the complaint. No further light seems to have been thrown upon the nature of diabetes until the time of Willis, who first pointed out the saccha- rine taste of diabetic urine. " The subjects of this affection," that able writer has remarked, " pass more urine than the whole quantity of fluids taken into the body; they have besides a constant thirst, and a slow kind of hectic fever always on them. It is very far from true, as some authors affirm, of the drink being again discharged with little or no alteration, for the urine in all that I have seen, (and I believe it will universally be the case,) differed not only from their drink, and from every other fluid in the animal body, but was like as if it had been mixed with honey or with sugar, and had a wonderfully sweet taste." Willis has ably investigated the principal pheno- mena of the complaint, and endeavoured to point out its seat; but he confesses his ignorance of DIABETES. 607 its causes and true nature. He has enumerated a variety of remedies adapted to the removal of the disease, but he admits the difficulty of ascer- taining what are the true purposes which ought to be kept in view in its cure. At the commence- ment of the diabetic tendency, he found a cure by no means difficult; but in the advanced stage of the disease, such a result very seldom occurred. This he supposed was owing to the crasis of the blood being only a little loosened, and thus rea- dily brought back again into its former state ; but when so much dissolved as to have most of its parts separated from each other, it could seldom, if ever, be restored. The treatise of Willis upon diabetes has been translated by Dr. Latham, and published in his " Facts and Opinions" concern- ing that affection. Sydenham, who lived for several years after Willis, and was cotemporary with him, has not alluded to the sweetness of the urine in diabetes, though he has left an extremely accurate descrip- tion of its causes and the indications of its cure. We shall not attempt to account for this silence J of Sydenham, by supposing, with Dr. Latham, that it arose from any other cause than mere inad- vertency. Experiment was then but a new branch of science; and the practice of tasting the urine of a diabetic patient was probably first adopted by Willis, of all men, from the beginning of time ; nor would the practical mind of Sydenham con- sider the announcement of more importance than if he had been told that the urine of hydrophobia was bitter; for what, in his time, was to be learnt from either ? After Sydenham, we meet with notices of this affection in the writings of Cullen and Heberden; and since their time many at- tempts have been made to elucidate its real nature, and to establish a successful mode of cure. Dr. Rollo, however, strongly roused the attention of the profession to the subject by the publication and extended circulation of Captain Meredith's case, in which he proposed a new and important plan of treatment. To that author every praise is due for having enabled us to form more correct notions of the nature and cure of this complaint. The names of Cruikshank, Girdlestone, Fother- gill, Dobson, Latham, Baillie, Lubbock, Bostock, Wollaston, Warren, Henry, Bardsley, Watt, Sat- terley, Prout, and Marsh, [Christison, M'Gregor, Bouchardat, Dezeimeris, R. Willis,] may be men- tioned as those of valuable contributors to the general fund of information which we now possess concerning this formidable malady. It has been supposed that diabetes is a disease of more common occurrence at the present time than formerly, because we meet with so few no- ] tices of the complaint in the writings of authors from Willis to Rollo, compared with the numerous authentic records of diabetic cases since the valua- ble publication of the latter physician. The fact seems to be that the disease is now better under- j stood, and its symptoms are more generally known, so that not a few cases which would for- merly have been classed under the head of phthisis or tabes, are now ascertained to be genuine exam- ples of diabetes. Dr. Storer, of Nottingham, states, in a letter to Dr. Rollo, that he had riot seen a single instance of diabetes during sixteen years in which he had the case of an infirmary, containing upon an annual average fifty-two in- patients, and three hundred out-patients. In the Manchester Infirmary, diabetic patients not unfre- quently present themselves for admission, and it generally falls to the lot of each of the medical officers of that institution to receive several cases under his care during the year. On inquiry, we have found that the same holds true with other extensive public hospitals. In private practice, too, instances of this disease are by no means un- common ; for we believe there are few medical men who have a fair share of professional employ- ment, to whom cases of diabetes have not some- what frequently occurred. Diabetes occurs -in early as well as in advanced life. Heberden erro- neously supposed that it exclusively attacked the aged and infirm. We have witnessed two in- stances of this disease in children under six years of age ; and Dr. Venables has also recorded seve- ral marked cases of infantile diabetes. A very distinct example connected with the process of dentition, and in which the urine was sweet, is related by Morton. More than half of the cases seen by Dr. Watt,—and he believed the same ob- servation would hold with regard to all that have been published,—occurred between the ages of thirty and forty-five; and of the other half a greater number were below the former of these ages than above the latter. " Of the whole," he says, " the best marked and most rapid in their progress have occurred in the very prime of life, and when the constitution was supposed to be in its full vigour. There is, perhaps, no period of life completely secure from the disease, though few instances have been recorded under the age of puberty. I have met with one instance in a boy of three years of age. It was most distinctly marked ; the urine amounted to six or seven pints daily ; the voracious appetite, urgent thirst, and arid skin were very remarkable. He had also phymosis, and afterwards suppression of urine. The disease terminated in a fatal dropsy." This disease not unfrequently makes its ap- proach insidiously; and it unfortunately happens that the first symptoms are often disregarded, and the complaint is allowed to advance for some time uncontrolled by medicine. The increased flow of urine is merely regarded as the necessary effect of the thirst, and the discovery of the saccharine condition of this fluid is also mostly accidental; but when hectic, emaciation, and debility have supervened, a more strict inquiry into the symp- toms is generally instituted, and the real nature of the complaint becomes fully ascertained. The almost constant desire to make water, and the insatiable thirst, particularly during the night, arc two most distressing symptoms ; the patient being obliged to be supplied with a large quantity of fluid near his bed-side, and having to rise six or seven times or oftener to evacuate the bladder. The urine has a slight straw colour, and sweetish taste, and yields on evaporation a considerable quantity of saccharine extract. The amount of this secretion passed during Ihe twenty-four hours is sometimes very considerable. It has exceeded, in more than one instance, seventy pounds. In the case of Smith, detailed in ihe v\ liter's •• Hos- pital Facts and Observations," thirty-six pints of urine were voided in the course of twenty-four 606 DIABETES. hours; and in that of Johnson, thirty-two pints. The discharge, generally speaking, is less than the liquid ingesta; but it has been found in one or two cases, that the liquid egesta have consi- derably exceeded the whole amount both of the solid and liquid ingesta. This fact, though denied by some writers, has been satisfactorily established by Dr. Bardsley, who has shown that the excess of the former cannot be accounted for solely on the supposition of its being derived from a general wasting and diminution of the solid and fluid parts of the system; for in two or three instances during the period in which the register clearly pointed out almost a regular daily excess in the amount of the urine compared with that of the liquids and solids taken, the patients had gained an accession to their weight of many pounds. " To what law or process of the animal economy," the author just named observes, " is the supply of this supera- bundant quantity of urine to be attributed ? Is it derived from cuticular or pulmonary absorption, or from a colliquation of the humours of the body ? Each of these modes has been insisted on by different writers." We receive the fact without framing any hypothesis to account for it The researches of modern physiologists, particularly those of Klapp and Dangerfield, do however render it extremely probable that this superabundant quantity of fluid is absorbed by the lungs from the moisture of the atmosphere. Numerous ob- servations demonstrate that almost every kind of matter in the state of fluid or vapour, introduced into the cells of the lungs, is rapidly absorbed from thence into the circulation, and, generally speaking, presents itself at the kidneys ; thus the oil of turpentine manifests itself in the urine within a few minutes ; and the amount of these facts goes to prove that there is a free and rapid absorption always taking place on the surface of the lungs. On the other hand absorption through the cuticle, if it exists at all, cannot be demon- strated ; while it is admitted by almost every one, that nine-tenths of the copious exhalation of the pulmonary surface, which, according to propor- tion, must at least be ten times as great as that by the skin, or twenty pounds daily, is constantly in the act of being re-absorbed by the pulmonary surface : and since the avidity of the absorbents is known to be greatly augmented, as in dropsy, by an increased diuresis, while the pulmonary exhalation must be proportionally diminished, it is easy to conceive that the absorption of the fluid excreted from the bronchi will be considerably increased, and thus augment the quantity of fluid egesta above the ingesta. There will, moreover, be absorption of part of the residual air in the lungs, and this will again supply itself from the now moister air brought in from the atmosphere by inspiration, to what extent it is not easy to compute ; nor can we reasonably expect that any such computation will correspond very exactly with the weights of the ingesta and body at different times, the means of taking which are often much more fallacious than is generally be- lieved. The mouth i* mostly dry and parched, the taste is peiverted, and the secretion of saliva altered. [Mr. M'Gregor found that it fermented briskly in a diabetic patient, when yeast was added to it, I and complaints arc often made of a constant sweet mawkish taste in the mouth, and a feeling as if the teeth were set on edge.] A tough viscid phlegm occupies the fauces; the tongue has a brownish fur on its centre, with florid edges; the ! gums are soft, spongy, and bleed on the slightest pressure of the tongue against them, being mostly ulcerated about the roots of the teeth ; the appetite is usually keen, and sometimes ravenous ; uneasi- ness about the stomach and bowels is experienced, chiefly after eating, and the contents of the former are not unfrequently.discharged in an acid and undigested state ; the skin is rough, dry, and un- perspirable; the bowels are generally costive; there is frequent pain and a constant sense of aching and weakness across the region of the kidneys, particularly on the least exertion; itching and excoriation, with phymosis of the prepuce, occurs in males, and an uneasiness about the meatus urinarius in females; the semen is discharged involuntarily, chiefly after voiding urine; and there is a total loss of the sexual propensities. Headach, impaired hearing, giddiness, and indis- tinct vision, are mostly present. When these symptoms continue only for a short time, they are followed by serious disturbance in the general health, such as extreme debility, languor, and great emaciation. The pulse, which is at first quicker than natural, becomes slow and feeble. The legs and ankles swell; and a tickling cough, with shooting pains in the chest, mostly harasses the unfortunate patient in the last stage of his disorder. The mind is extremely peevish, irrita- ble, and somewhat suspicious; the spirits are low and depressed. By attention to the above symptoms, it is not, ' we conceive, difficult to distinguish diabetes from every other disease. There may be a preterna- tural discharge of urine in other affections ; but in this only is a saccharine condition of that se- cretion present. Most of the more severe symp- | toms of this disease are attributable to the im- mense amount of solid matter which is constantly draining off from the body ; and indeed some diabetic patients seem to sink merely from the de- bility occasioned by the continued secretion of an unnatural quantity of urine containing so large a proportion of animal extractive matter. The ap- petite, though voracious, is inadequate to the sup- ply of nourishment sufficient to balance the im- mense and rapid waste which is daily taking place. " The loss of so much matter," Dr. Elliotson ob- serves, " from the system, sufficiently explains the hunger, the feeling of emptiness and sinking in the stomach, the emaciation, debility, anaphro- disia, coldness of the legs, pain both of them and of the loins, the depression of spirits, &c. without attributing the disease to the stomach or the kid- neys exclusively. The excessive escape of fluid, or when this does not take place, the feverishness, | equally explains the thirst and dryness of the skin." I It will be shown, when we come to the consi- deration of the pathology of diabetes, that it is i mostly complicated with disease in some impor- tant organs. Dr. Willan observed that he never | met with a confirmed case of this disease in which there was not some considerable disorder of th« | constitution, or a defect in some organ essential DIABETES. 609 to life. Our experience leads us to hold this re- mark as not far removed from truth; although it may be said that the constitutional affections are more frequently the effects of the progress of dia- betes, than the concomitants of ite commence- ment Pulmonic affections, we know, not un- frequently precede or accompany diabetes. Dr. Bardsley remarks that he scarcely recollects an instance of the disease where a slight affection of the chest did not more or less prevail. In several instances, too, on record, a connection between phthisis pulmonalis and diabetes is strikingly marked. The phthisical symptoms existing pre- viously to the attack of the latter disorder are often suspended by its influence ; but on the par- tial removal of the diabetic complaint, the tuber- cles pass rapidly through their several stages, and the patient's sufferings are terminated by death. A similar suspension of the progress of disease in the lungs is sometimes noticed in females who become pregnant whilst labouring under the symp- toms of confirmed phthisis. The cough, expec- toration, and hectic fever, almost entirely disap- pear, pregnancy advances, and labour ensues; when in the course of a few weeks (sometimes days) the pulmonary symptoms return with ag- gravated severity, the strength rapidly declines, and life is soon extinct. In the more confirmed cases of this disease which have fallen under our notice, there has been generally present a teazing tickling cough, sometimes attended with .purulent expectoration, and mostly with dyspnoea, and shooting pains in the chest. The most common exciting causes have been, according to our experience, frequent exposure of the body to sudden alternations of heat and cold, and an indulgence in copious draughts of cold fluid when the system has been over-heated by labour or exercise. In twelve cases that have come under our observation, the patients have at- tributed their ailment to one of these causes; hence, we have observed this affection chiefly amongst that class of artisans whose occupations expose them to sudden changes of temperature, or who reside in damp and low situations. The intemperate use of spirituous liquors, poor living, and distress of mind, not unfrequently operate, too, in the production of this disorder. It is a curious analogous fact, that dogs and rabbits fed upon rye-meal, or on decoctions of wheaten flour, have a species of diabetes produced ; as has been ascertained by the experiments of Dr. Krimer of Halle. The secretion of urioe becomes much in- creased : the urea and uric acid almost or alto- gether disappear; the animal becomes emaciated ; and in place of sugar, the urine is found loaded with albumen and mucus. The origin of the complaint has been traced by some patients to sleeping out the whole of the night in the open air, in a state of intoxication. The subjects of this disease have been mostly liable to profuse sweating upon any ordinary exertion, and at such times have been accustomed to abate thirst by drinking freely of cold liquids, or by eating im- moderately of acid fruits, thus suddenly checking perspiration. The state of the mind seems lo have a more intimate connection with this affec- tum than has been generally supposed. In seve- ral cases on record, mental anxiety and distress Vol. I. — 77 have been assigned as its chief cause. Indeed, a temporary diabetes insipidus is a very ordinary effect of such a state, and the despondency of mind throughout the disease is distinctly alluded to by Aretaeus, and by many other eminent writers. We have not observed the characteristic odour, compared to that of hay, from the persons of dia- betic patients, to which Dr. Latham has particu- larly alluded. It has been supposed that the phy- mosis before noticed as a symptom of diabetes, proceeds from the extreme sensibility of the ure- thra, which subjects it to the general irritation of the system so frequently present in the complaint, and thus renders it morbidly sensible to the stimu- lus of the urinous fluid. With respect to the emaciation, it may be re- marked that Dr. Lubbock considered it a leading circumstance in this affection: for in his expe- rience it came on slowly, the subject of it not perceiving much deviation from health. " I have at this time," he observes, " two patients who, excepting a slight and very gradual wasting of the body, some increase of thirst, with occasional un- easy sensations about the stomach, to which may be added, feebleness of sight at times, and an habitual tendency to phymosis, possess that degree of apparent health and strength that would mis- lead a common observer." He conceived that the emaciation claimed the first attention of the phy- sician ; as without the removal of this symptom, neither the reduction of the urine, the alteration of its quality, nor the appearance of considerable remaining muscular power, could prove that the disease had yielded to any curative process. Diabetes frequently occurs in the scrofulous habit, but is not confined to it alone. Some au- thors are of opinion that the disease may be he- reditary ; thus Dr. Prout observes, he cannot doubt but that a predisposition or tendency to this affection exists in some families, as he has wit- nessed four distinct instances of such a circum- stance. The first was that of a young man whose mother and uncle had died of the disease; the second was that of a lady about fifty years of age, whose brother or sister had sunk under the complaint; the third was that of a girl about ten years of age, whose father two or three years be- fore had died of the same affection ; the fourth instance was that of a gentleman, aged fifty-four, who died of this affection, and whose father had laboured under the same disease for several years. Dr. Storer has noticed the occurrence of three cases of diabetes in one family, in the persons of a brother, sister, and her daughter. The father of the two elder died of that affection. In an- other instance, related by Mr. Leigh Thomas, three brothers in one family laboured under dia- betes. Morton has also alluded to the hereditary nature of the disease. We believe that a tendency to it is occasionally inherited ; but further expe- rience and a more extended inquiry on this point are necessary, before diabetes can be correctly ar- ranged like scrofula, phthisis, mania, and apov I plexy, under the head of family diseases ; for in not a few instances no hereditary origin can be I traced. Yet, it must be observed, that even of j these diseases, no two have exactly the same here- ! ditary influence, nor are any two of them modi- \ fied exactly in the same degree by circumstances j 610 DIABETES. while all of them are seen to spring up every day in cases where no hereditary taint can be suspect- ed ; so that, if a comparatively rare disease like diabetes has been found by Dr. Prout hereditary in four times out of twenty, it seems fair to ad- mit, that, as in the case of a great many other diseases, ite supervention is often greatly favoured, if not determined, by hereditary conformation; and little more can be said even of scrofula or mania. Various opinions have been formed concerning the proximate cause of diabetes. Thus some authors of eminence, like Mead, have supposed that it depends on a " morbid state of the liver and bile;" some, as Dobson, Home, Cullen, and Rollo, believed that it proceeds from a defect in the assimilatory organs; whilst others, as Dupuy- tren and Thenard, have attributed the principal phenomena of the disease to a " morbid action of the kidneys." Dr. Baillie also thought it proba- ble that diabetes was owing to a deranged action of the secretory structure of the kidneys, by which the blood there is disposed to new combinations ; and that the effect of these combinations was the production of a saccharine matter. He at the same time imagined that the chyle might be, so imperfectly formed as to cause the blood to be more readily changed into a saccharine substance by the action of the kidneys. The ingenious au- thor of the Zoonomia conceived that diabetes was produced by a retrograde motion of the absorbent vessels, owing to which chyle passed from the lacteals into the lymphatics of the kidneys or bladder. Cawley thought that in this disease the tubuli uriniferi were enlarged or relaxed, by which the chyle escaped into the urine. Willis conclud- ed that diabetes depended upon a dyscrasy or in- temperament of the blood, resulting from a mor- bid action of the assimilating powers. "Thus," he observes, " diabetes is rather and more imme- diately an affection of the blood than of the kid- neys, and it thence has its origin, inasmuch as the mass of blood becomes, as it were, melted down, and is too copiously dissolved into a state of serosity, which indeed is very manifest from the quantity of urine so immensely increased, which cannot arise from any other cause than from this solution and waste of the blood: whence also the blood, which is left in the body, the serum being thus copiously abstracted from it, becomes much thicker and more apt to coagulate, as we may infer from the quick and laborious pulse; for on that account the heart acts with more rapidity, that the blood, which it thus agi- tates more than is usual, may be preserved from coagulating." The two hypotheses, however, which refer the seat of the disease to a morbid action of the stomach, and a morbid condition of the kidneys, have been most generally adopted. " Were I to give a theory," says Dr. Home, >• to explain the nature and symptoms of this wonder- ful disease, I would say that it arises from a de- fect of the animal or assimilatory process, by which the aliment is converted into the nature of our body." Dr. Home considered the excess or defect of this process as the source of many disorders. Rollo, too, observes that the immediate cause of diabetes mellitus is a morbid condition of the sto- mach, forming or evolving from vegetable sub- stances saccharine matter, which is quickly sepa- rated as a foreign body by the kidneys. " But, to be more particular," he continues, " we allege that this disease consists in an increased morbid action of the stomach, with too great a secretion, and an alteration in the quality of the gastric fluid, pro- ducing saccharine matter by a decomposition of the vegetable substances taken in with the food, which remains unchanged." It has been urged, and with reason, as a very serious objection to the theory of Dr. Rollo, that no sugar has been de- tected in the blood of diabetic patients; a fact which we shall shortly show to be established by the interesting experiments of Wollaston, Marcet, Nicholas, Gueudeville, Thenard, Bostock, Vau- quelin, Segalas, and other able chemists. In several instances of the disease which have come under our own examination, there certainly has been ample evidence of preceding stomach derangement; but admitting that the stomach is generally in a state of morbid activity, as may be inferred from the increased and almost insatiable appetite which accompanies the disease, still we are ignorant of the particular condition of the primae viae which leads them to favour the extrac- tion of sugar. Dr. Henry thinks that the theory must be modified by assuming that the blood which reaches the kidneys contains the elements of sugar, and is deficient in those of urea. He supposes, however, that it is necessary to a just pathology of the disease that some morbid condi- tion of the kidneys should be admitted, though of a kind which has not yet been explained by ana- tomical investigation. Dr. Mason Good conceived that a morbid and highly irritable state of the kidneys was sufficient to account for every other derangement that marks the progress of the disease. He saw no necessity for supposing an idiopathic affection of any other part, whether the stomach or the nerves, the digestive or the assimilating powers ; but decides, from the attention which he has paid to the nature of diabetes, both in theory and practice, that the whole of its phenomena may be traced to renal | mischief, and consequently that it is a far less complicated affection than has hitherto been sup- posed. That the kidneys are frequently in a state of irritation is evident from the pain, heat, and weakness, experienced in those organs, and the augmented urinary secretion. Dr. Lubbock seems to have noticed the coinci- dence of the parched and dry skin with the sac- charine quality of the urine, from which he was induced to believe that in this affection the want of perspiration or excretion from the surface is connected with sweetness of the urinary fluid ; and this belief was supported by an examination of the nature of the perspirable fluids, and of the component parts of saccharine matter. On this view he has formed a theory of diabetes. " Ifhas | been proved," he observes, " that sugar is, for the | most part, composed of carbon, oxygen, and hydrogen, united in a certain ratio; and it ap- pears, by the experiments of Cruikshank and Abernethy, that, besides the occasional aqueous fluid discharged daily from the surface of the body, I about three gallons of carbonic acid are also lost I to the system by the perspirable matter. Now DIABETES. 611 supposing, as happens in diabetes, this perspirable excretion, or carbonic acid, is suppressed and retained in the system, it is probable that the car- bon and oxygen of the acid so retained, by enter- ing into a due combination with some portion of the hydrogen of the animal body, may tend to the production of the saccharine matter of the urine; and as the carbonic acid is the general product of the vegetable world, it would follow that its reten- tion in the animal body may produce the pheno- mena of the defective animalization, characterising diabetes as exhibited in the formation of sugar." Dr. Latham has broached a very fanciful hypo- thesis concerning the proximate cause of diabetes, founded chiefly on the dyscrasy of Willis, and the selecting power of the kidney. As it is impossible to condense it, we shall be satisfied with merely mentioning that it is quite as untenable as some of ite ancient predecessors. Dr. Ferriar has also given a very vague opinion in explanation of the phenomena of this disease. He supposes that if the extreme vessels should from any cause take on a morbid action, and, instead of supplying nutri- tious matter, should form a substance which cannot be applied to renew the waste of the system, the diseased secretion must either accumulate in the intermediate passages of the circulation, where it would produce hectic fever, (by absorption,) and subsequently death ; or it must be carried off by some of the emunctories, to which its stimulus must cause an increased determination of fluids. This he conceives to be precisely the case in dia- betes. He afterwards refers the secretion of sac- charine matter in the kidneys to metastasis, and supposes it to* arrive there by the circuit of anas- tomosing branches. In a reply to some strictures of the reviewer in the Medical and Physical Journal, on a case of diabetes related in the sixth volume of the Edin- burgh Medical and Surgical Journal, the editor observes that the discharge in diabetes may be a diversion of a profuse secretion from the skin to the kidneys ; that besides being morbidly profuse, it is, like other secretions, susceptible of a change, and may become stimulating even to the skin itself, and consequently much more so to the kid- ney, where it then must certainly act as a foreign body exciting the organ to extraordinary action ; and that in the enlarged and excited state of the vessels of the kidney, time is not allowed for the secretion of urine to be perfect, and that chyle niuy pass off with it, or it may be called the urine of digestion or of the chyle, which in the healthy state ij passed two or three hours after a meal, and cannot be considered a natural secretion. M. Dezeimcris supposes that the proximate cause or essence of diabetes consists in irritation of the kidneys; that this irritation is rarely primitive, being mostly the result of chronic gastritis. In the course of the latter affection there is extreme thirst; the patient drinks freely, and the urine is in proportion: this state is prolonged; the activity of the kidneys increases every day at the expense of that of the other excretory organs; they remove from the body those fluids which require constant renewal, and thus again contribute to augment the thirst Such are only a few of the hypotheses which have been framed to explain the nature of diabe- tes ; but they are sufficiently numerous to show how little is really known respecting it One great cause of this diversity of opinion is, as we shall hereafter show, the defective aid afforded by pathological investigation. » Pathological anato- my," as the late celebrated Laennec justly re- marked, " is incontestibly the surest guide of the physician, either in the recognition of maladies, or in the cure of those which are susceptible of cure." We have no theory of our own to pro- pose ; but from all the attention which we have been able to pay to the subject, and from what we have seen of the disease itself, it appears to us proper to admit that the natural and healthy action of both the stomach and kidneys is materially dis- turbed ; the former perhaps primarily, and the latter secondarily; and that the dry and unper- spirable condition of the skin is much more in- timately connected with its production than is generally supposed : thus diabetes is an affection not proceeding from a morbid action of one par- ticular part, but of several important organs. This statement is sanctioned by facts, and seems to derive confirmation from the symptoms, the remote causes, the effects, and analogy with other diseases. We have used the word perhaps in the above allusion to the primary derangement of the stomach, because in several diabetic cases on record the increased secretion of urine preceded every other symptom. So constant is the sympa- thy between the kidneys and the stomach, that Sydenham himself has declared there is no other mean of distinguishing between nephritis and lumbago than the expression of this sympathy in the former case by vomiting. It is possible that increased action of the kidney may very early, though not primarily, call the stomach into sym- pathy. In a communication from our friend Dr. Milligan of Edinburgh, he remarks that the fa- mous Peter Petit asks, in his Commentary upon Aretaeus, if the excess of sugar is furnished by an error of the digestive process, why does it not pass off by the bowels, the lungs, or the skin, as well as by the kidney ? " But this very profound and philosophical question is very easily answer- ed by the practical observation, that we know, as a matter of experience, that any excess of fluid introduced into the circulation does not readily pass off by the skin, lungs, or bowels, but seems naturally and designedly in almost every instance to be carried away by the route of the kidneys and urinary passages; and that, therefore, we have a right to expect that it will be so here. But it does not follow from this that the first profusion of urine in diabetes is saccharine, nor yet that the initial steps of the malady are to be traced to er- rors in the action of the stomach or the skin: nay, so great is the number of persons who at all times labour under disease of the two latter organs, that on diabetes commencing we should require very strong proofs that some aggravation of the mor- bid condition of these parts, unconnected with any suddenly interposed cause, took place at the time, before we admitted that they were instrumental in producing diabetes." [For some other views on the nature of Dia- betes, see page 617.] We must next allude to the prognosis to be generally formed in this malady. It has been 612 DIABETES. satisfactorily proved that a saccharine condition of the urine may exist during several years with- out the general health being materially affected, or the powers of the stomach much impaired. Diabetic patients, whose mode of living has been on the whole temperate, have been known, in not a few instances, to reach advanced age. It is in those cases, chiefly, where the constitution has been previously injured by long-continued and frequent irregularities that the disease under con- sideration proves rapidly fatal. Whilst the diges- tive organs continue to perform their functions with tolerable vigour, the supply of nutritious matter will be found nearly adequate to balance the waste which is daily taking place from the increased quantity of the urinary secretion. We have at this time two diabetic patients, who, ex- cepting some increase of thirst and urinary dis- charge, and occasional disturbance of the diges- tive organs, enjoy a fair share of apparent health and strength, and are fully equal to the various exertions that devolve upon them in the ordinary intercourse of life. The disease, however, ought to be viewed with much concern, for it is too apt to pursue its fatal'progress in defiance of all the resources of our art It is difficult to establish a perfect cure when the characteristic symptoms of the affection have been once fairly developed. We find that even Aretaeus alluded to its fatal nature. He has remarked, " that the disease is chronic, and generated by length of time ; but short is the life of man when its establishment is fully com- pleted." The perfect recovery of the patient de- pends upon the removal, not merely of one, but of the whole of the symptoms; for one may be relieved by the aggravation of another. Though there may be a considerable reduction in the quan- tity of the urine, still if there be no alteration in its quality, and the saccharine impregnation con- tinues, the disease cannot with propriety be said to have yielded to any curative process. It is by close attention to, and an early discovery of the premonitory symptoms that we must hope to pre- vent a fatal termination. The disease unques- tionably may be controlled at its commencement by the employment of the means hereafter to be pointed out; but it unfortunately happens that the malady has in most instances made consider- able progress before the patient's attention has been called to its real nature. Rollo, Beddoes, Cleghorn, Watt, Bardsley, and others have related cases of diabetes in which a cure has been effect- ed ; but this happy result is by no means of com- mon occurrence. When the disease is complicated with phthisis, scirrhus, or other organic mischief in any important organ, all hope at once disappears. With regard to the perfect cure of diabetes, it is certainly necessary to speak with much cau- tion ; for, like some other formidable diseases, it is for the most part only capable of being relieved, and not of being effectually removed. " Within the last six or seven years," says Dr. Prout, '«nearly twenty cases of diabetes have fallen un- der my observation ; and among these, I have never but in one instance, and in that for a very short time only, seen the urine of a diabetic pa- tient rendered quite natural." Dr. Lubbock, too, never saw this disease yield to any curative mea- sures ; the emaciation continued to increase more and more, until after a lingering and protracted state of suffering, the unhappy subjects of it at last gradually sunk. Of twenty-nine diabetic pa- tients who have been under our care, sixteen have eventually died, strongly evincing the fatality of the disease; eight out of the remaining thirteen have perfectly recovered ; and of the other five we have received no account. The chances of restoration to health are frequently diminished by the irregularities of the patients themselves, in deviating from the prescribed modes of treatment, notwithstanding the strongest promises on their part to comply strictly with the wishes of the practitioner. Previously to enumerating the morbid changes which have been observed after death in diabetes, it may be well to inquire what light has been thrown upon the pathology of this disease by che- mical analysis of the urine and blood of diabetic patients. Sensible Properties and Chemical Anal- ysis of the Urine in Diabetes Mellitus.— Several distinguished chemists (amongst whom may be mentioned the highly respectable names of Cruikshank, Fourcroy, Nicolas and Gueude- ville, Thenard, Vauquelin and Segalas, Dalton, Bostock, Henry, and Prout) have sedulously oc- cupied themselves in investigating the properties of diabetic urine, and have performed a variety of interesting experiments, with the view of de- termining the precise nature of that morbid secre- tion. The sweet taste of diabetic urine seems, as before observed, to have been first distinctly pointed out by our countryman Dr. Willis. Since his time, the existence of sugar in the fluid has been satisfactorily determined. It is worthy of remark, however, that the saccharine impregna- tion of diabetic urine is not at all times discover- able by the taste; for that secretion has been found to vary at different intervals during the twenty-four hours. In the case of a young lady, related by Mr. Shirreff, the urine voided at one o'clock was free from sweetness and perfectly in- sipid ; some time after it appeared natural, but two hours after dinner was sweet, and in the evening again perfectly natural. The urine in this disease has, it has been already said, a pale- straw colour. It is mostly clear when first voided, but on standing some time in the vessel, not un- frequently deposits a white flaky precipitate. Its smell at first strongly resembles that of new hay, but in the course of a short time a faintish acid odour may be perceived. It has been stated that the temperature of diabetic urine, when recently voided, is lower than that of the healthy secretion; but this is a point which we have examined with much care, and we have found that no marked difference exists between them. An important circumstance connected with the consideration of the peculiar character of diabetic urine is its spe- cific gravity. The profession is under obligations to Dr. Henry for having satisfactorily shown that the specific gravity of the urine in diabetes melli- tus is higher than in healthy urine; a circum- stance which had been overlooked by some of the most eminent writers on the chemical history of that disease. In ten cases of diabetes where he had an opportunity of determining this property, it never fell short of 1028 nor exceeded 1040; DIABETES. 613 1000 parts of water at 60° Fahrenheit being taken as the standard ; whereas in healthy urine he never found the specific gravity, under any cir- cumstances, to exceed 1020. Dr. Henry has re- cently informed us that subsequent trials of the specific gravity of the first morning's urine of healthy persons lead him to believe that this is understated, though perhaps a fair average for the whole day. Dr. Henry considers the specific gravity as a most useful test of the existence of diabetes in doubtful cases, and, when taken along with the actual quantity discharged, as furnishing a tolerably correct idea of the degree of morbid action. " It may be objected, perhaps, (he ob- serves,) to the employment of this test, that it requires more familiarity with the method of tak- ing specific gravities than falls to the lot of the greater part of medical practitioners. By means, however, of an hydrometer, which is well known to practical chemists, and which may be readily procured at a small expense, the specific gravity of the urine may be taken in a. few moments, and with the greatest accuracy, by a person wholly unaccustomed to experiments of this kind." Deeming it desirable to establish a connection between the quantity of extractive matter and the more certain character of specific gravity, Dr. Henry engaged in a series of carefully-conducted experiments, and from them constructed the fol- lowing table, which exhibits at one view the quantity of solid matter in diabetic urine of dif- ferent specific gravities between 1050 and 1020. The scale may be extended, however, by the rule of proportion, to any case in which the urine may be found to have a specific gravity above the former or below the latter of those two numbers. In the experiments which furnished the above data of the table, the urine was evaporated by a steam heat till it ceased to lose weight, and till it left an extract which became quite solid in cooling. Specific gravitvof urine compared with 1000 p;irts of water at (j0°. 1020 1021 1022 1023 1024 1025 1026 1027 1028 1029 1030 1031 1032 1033 1031 1035 1036 1037 1038 1039 1040 1042 1044 1046 1048 1050 Quantity of soIid'Q,uantity of solid extract in a wine^ extract in a wine pint, in grains! pint, in and tenths 382.4 401.6 420 8 440. 459.2 478.4 497.6 516.8 536. 555.2 574.4 593.6 612.8 632. 651.2 670.4 689.6 708.8 728. 747.2 766.4 804.8 843.2 881.6 920. 958.4 0 15 0 10 1 9 2 8 0 1 1 0 2 1 2 3b By referring to this table, we can readily ascer- tain the quantity of solid matter voided by a dia- betic patient in a given time. Thus, as Dr. Prout has noticed, suppose ten pints are passed in twen- ty-four hours, of the average specific eravity 1040, it is evident that this will contain 10X1- .4..2..6 = 15.. 7..2, or upwards of a pound and a quarter of solid extract. The quantity of extractive matter obtained from ' diabetic urine is liable to considerable variation : J but it is for the most part in proportion to the vio- [ fence and severity of the disease, especially when the patient is not confined to any rules of diet. ft has amounted in a few instances to more than two ounces from one pint (wine measure) of the fluid; but the medium quantity in even very ag- gravated cases of diabetes mellitus may be fairly estimated at not more than ten drachms of solid extract. The specific gravity, too, sometimes changes in a very remarkable manner. In the case of a patient lately under our care, it was re duced in the course of two days from 1033 to 1022, and very shortly afterwards it reached 1042. In another instance, alluded to by Dr. Prout, the specific gravity was reduced in-about sixty hours after the patient had commenced with the use of opium, from 1038 to 1.1074. The saccharine matter had apparently disappeared, and was after- wards superseded by urea, the quantity of which had become excessive. The able author just mentioned has shown that an excess of urea frequently precedes the appear- ance of saccharine matter in the urine. " Now it is a remarkable fact," he adds, " that in diabetes, in proportion as the saccharine matter diminishes under the above plan, that of urea generally in- creases ; and in such instances the presence of the former principle cannot only be no longer dis- tinguished by the sensible properties of the urine, but scarcely be demonstrated by the utmost skill of the most experienced chemist, though the spe- cific gravity of the urine may at the same time be nearly 1040." Sometimes sugar is wholly want- ing in diabetic urine even when the urea has al- together disappeared. Dr. Young met with an instance of this kind. After evaporating the fluid in a gentle heat, a brown substance was dissolved in abundance in alcohol, and afforded a stiff ex- tract, which contained the lactic acid with a little trace of lactate and muriate of ammonia, but con- sisted almost entirely of the animal extract which accompanied the lactates, was precipitated by tan- nin, and left after combustion a little muriate of soda, which showed a slight trace of uncombined alkali. It has been matter of dispute whether urea is contained, in any proportion whatsoever, in dia- betic urine. Whilst Cruikshank, Dalton, Four- croy, Nicolas and Gueudeville, Thenard and Bos- tock contend for the non-existence of urea in the urine of patients labouring under diabetes, Henry and Prout maintain that, although the quantity of that substance be very much diminished, still it is never entirely absent. Dr. Bostock published a highly valuable paper on diabetes in the 6th vo- lume of Memoirs of the Medical Society of Lon- don, in which he stated that he had procured nitrate of urea in abundance, along with oxalic acid, from the extract of diabetic urine. He was 614 DIABETES. afterwards induced to repeat his experiments at the request of Dr. Bardsley, who sent to him several pure specimens of siccharine extract for examination, having himself failed in several in- stances to detect any urea in diabetic extracts. The result was, that Dr. Bostock found his for- mer inference to be. erroneous, and with a candour very honourable to himself, acknowledged that we have no evidence of the existence of urea in dia- betic extract. In the experiments of the seven first named chemists, the test employed to detect the presence of urea was the addition of nitric acid to the ex- tract of urine dissolved in a small quantity of water. On treating extracts obtained by slow evaporation from healthy urine in this manner, they found that a copious precipitation of nitrate of urea always ensued ; whereas in their trials with diabetic extract they seem to have failed to discover any traces of urea. Dr. Henry, however, has satisfactorily shown by several experiments conducted for the purpose, that the action of nitric acid on the urea may be prevented by its agency on the greater proportional mass of sugar. He has stated that urea cannot be made apparent by nitric acid in the extract from any mixture of dia- betic and natural urine, when the former exceeds the latter in a greater proportion than that of six to one; or when the solid urea is less than one- twentieth of the weight of mixed extract It is on the ammonia which comes over early in the distillation of diabetic urine, that Dr. Henry seems disposed chiefly to insist, as establishing the pre- sence of urea, because there is no other animal substance which can give origin to the volatile alkali under such circumstances. " Another proof (Dr. Henry observes) of the existence of some portion of urea in diabetic urine, may, in many instances, be obtained by a careful observation of the phenomena attending its spontaneous decom- position. At a temperature exceeding 60° Fah- renheit, diabetic urine passes rapidly to the acetous state. But if the succession of changes be care- fully watched, it will be found that there is a point at which, before it becomes acid, it exhibits, to sufficiently delicate tests, distinctly alkaline pro- perties." " The deficiency of urea in diabetes," he adds, " may be stated as being very considera- ble. In those cases where I have attempted to estimate it, from the quantity of ammonia evolved by the destructive distillation of the urine, the urea has not appeared to exceed from l-40th to l-60th the quantity contained in an equal mea- sure of concocted healthy urine. One specimen of diabetic extract, with which I was favoured by Dr. Bardsley, approached so near to perfect white- ness, that there appeared to me little reason to expect any evidence of its containing urea. Yet even in the product of the distillation of this ex- tract, after being rectified with the addition of potash, ammonia was found. On distilling, also, a portion of the urine itself, the condensed liquor gave manifest traces of carbonate of ammonia. This urine, however, contained a far less propor- tion of urea than I had ever before ascertained ; not exceeding, as nearly as I could estima^ l-80th of the natural quantity. Making every allowance, then, on account of the increased flow of urine, it will appear that the quantity of urea discharged by persons labouring under diabetes, in any diurnal interval, falls considerably short of the quantity voided in a state of health." We have repeated these experiments with great care on an extensive scale, and are satisfied with their accuracy. Dr. Prout also considers the absence of urea as by no means characteristic of diabetes. He admits that in this, and some other affections of the urine, very little urea is sometimes present; but the same he shows to hold with respect to the other principles, many of which are deficient in such urine as well as urea. He never met with a specimen in which it was entirely absent. It may in fine be correctly stated that there exists a defi- ciency, though not a total want of the urea, in the urine discharged in well-marked cases of diabetes mellitus. [It would appear, however, from the observa- tions of Messrs. Christison, M'Gregor, and Bon- chardat, that urea is generally contained in dia- betic urine in larger relative proportion than in health, but that it is masked by the presence of sugar, and cannot be discovered by the addition of nitric acid, except by peculiar management] It may be proper to notice the effects produced by certain re-agents, and by evaporation, on diabetic and healthy urine, according to the expe- riments of MM. Nicolas and Gueudeville. I. Tincture of turnsol added to diabetic urine re- ceived a reddish violet tinge; with healthy urine it assumed a deep red. 2. Nitrate of silver occa- sioned in diabetic urine a curdy precipitate, of which the colour, at first white, soon changed to violet, and the liquor became limpid with a slight tinge of yellow; it was altogether inodorous. With healthy urine the same re-agent afforded an abundant precipitate of a deeper violet colour, and the liquor preserved a yellowish red colour, and emitted a strong urinous odour. Each precipitate consisted of nitrate and phosphate of silver. 3. Lime-water produced a milkiness in diabetic urine, immediately rendering it turbid, and affording a faint ammoniacal odour. After some time a floc- culent precipitate occurred, of which a part re- mained on the surface of the liquor, which became as limpid as water: this precipitate was phosphate of lime. The same test also rendered healthy urine opaque, and the precipitate was white and extremely buoyant; but the liquid preserved a fine lemon-colour; the precipitate, a phosphate of lime, was also more abundant by one-half. 4. Concentrated sulphuric acid added to diabetic urine afforded a beautiful rose-colour, occasioning at first a slight effervescence. The surface of the fluid became covered with a light froth, which remained for a long time, and there was scarcely any precipitate : the liquor was inodorous. At the instant of mixing sulphuric acid with healthy urine, the effervescence was scarcely perceptible and the foam was slight. The liquor assumed a reddish brown colour, and preserved the odour of urine: at the bottom of the vessel was observed a small quantity of a darkish red precipitate. Dr. Henry has mentioned to us that on adding nitric acid, moderately diluted, to diabetic urine, he has often observed a change of colour to a red, resem- bling that of a weak acidulated infusion of rose- leaves, and an immediate and very sensible in- crease of the saccharine odour. 5. Muriate of DIABETES. 615 barytes rendered diabetic urine somewhat turbid ; | and in a short time a slight precipitation took : place of a white salt, which was sulphate of ! barytes. The same re-agent produced a like effect | upon healthy urine: but the precipitate was I rather more abundant, and of a brownish red co- lour. 6. Oxalic acid afforded with diabetic urine a light rose-coloured flocculent precipitate, of which a considerable part was held in suspension in the liquor. The same acid threw down a pre- cipitate with healthy urine, but it was heavier and of a deeper colour. 7. Sulphate of mercury rendered diabetic urine slightly turbid, and gave it the appearance of a white salt A precipitate of a reddish tinge gradually occurred, one-half of which remained suspended in the liquor. Treat- ed by the same re-agent, healthy urine assumed a brownish red tinge : the precipitate resembled a lilac-coloured salt, and was wholly deposited at the bottom of the vessel. It was the phosphate of mercury. 8. Pure potass rendered diabetic urine turbid, and afforded a small portion of am- monia; a white precipitate was afterwards pro- cured in small quantity. The precipitate afforded by the same re-agent with healthy urine was on the contrary abundant, and the disengagement of ammonia very considerable. 9. Muriate of lead communicated to morbid urine a milky co- lour ; the precipitate which ensued was that of a white salt, slightly tinged with red ; it was a phosphate of lead : the liquor remained transpa- rent Muriate of lead imparted to healthy urine a violet colour, and produced a red precipitate; the liquor remaining of a brownish red colour. 10. Diabetic urine precipitated nitrate of mercury of a rose colour, and the liquor became as limpid as water. The precipitate of nitrate of mercury by healthy urine was also of a rose colour, but more abundant; and the liquor preserved a brown tinge. Analysis by Evaporation.—1. After exposure to the air during six weeks, (from 10° to 12° Reaumur, 54° to 59° Fahr.,) diabetic urine be- came turbid within the first six days, and gradu- ally deposited a white flocculent substance, which was found to be albumen. The liquor afterwards became limpid and slightly coloured, having a sour odour and acid taste exactly resembling vine- gar made with milk. Healthy urine, after like exposure to the air during the same period, soon exchanged its natural odour for one that was strongly ammoniacal; its colour became brown, and in the end it putrefied, affording a very fetid and offensive smell. The precipitate was pulve- rulent, and composed of phosphate of lime, soda, and muriate of soda. 2. Diabetic urine became acid, and turned blue vegetable tinctures red; whereas, healthy urine, when putrid, rendered the same tinctures green. 3. This acid urine combined perfectly with carbonate of potass in so- lution, without marked effervescence ; the liquor, after filtration and evaporation, furnished acetate of potash, mixed with a small quantity of phos- phate of potash; the precipitate obtained was scanty, of a white colour, and composed of lime and a small portion of magnesia. 4. Four pounds of diabetic urine afforded, on evaporation carefully conducted, four ounces and a half of extract, of the consistence of honey, of a brown colour, like to treacle, and having the odour of burnt sugar; whereas only three ounces six drachms of an extract of the consistence of honey, of a very brown colour and urinous odour, were obtained from four pounds of healthy urine. 5. Ten parts of diabetic extract were mixed with four of muri- ate of lead and one of powdered charcoal, and after being dried they were submitted to distilla- tion in a retort. Little or no ammonia was afforded, but carburetted hydrogen and a black fetid oil. The residue in the retort, on being subjected to an intense heat, gave no traces of phosphorus. The extract of healthy urine, treated in the same manner, furnished ammonia and a fetid oil; the residue contained some muriate of ammonia, and when thrown upon ignited char- coal, emitted the odour of phosphorus. 6. One ounce and two drachms of diabetic extract being treated with four ounces of alcohol, at 35° Reau- mur, afforded a yellow fluid resembling Spanish wine; the solution of the matter was nearly com- plete, and the liquor deposited, in the space of twenty-four hours, a light, flocculent, grey sub- stance, which, when washed and dried, weighed only twenty grains; its taste was saline and slightly sweet. Lime-water, added to one por- tion of the residue, afforded a feeble ammoniacal odour; sulphuric acid, applied to the other por- tion, changed it to a black colour, and produced the odour of sulphurous acid gas, indicating the presence of albumen. An equal quantity of the extract of healthy urine, treated with alcohol, afforded an abundant precipitate, composed of the phosphates of magnesia, lime, soda, and ammonia, uric acid, benzoic acid, and albumen. Urea and the muriates of ammonia and soda were held in solution in the liquor. In, order to obtain these different substances separately, the fluid was evaporated, and the residue being dissolved in water, nitric acid was added to it, which occasioned a copious precipitate. This precipitate was found to be a nitrate of urea. 7. On submitting diabetic extract to distillation with nitric acid, nitrous vapour was disengaged ; the residue being dissolved in dis- tilled water afforded, on evaporation, oxalic acid, and a small portion of phosphoric acid. 8. Four ounces and a half of diabetic extract, of the con- sistence of honey, being dissolved in a pound of distilled water, with half an ounce of yeast added to it, and exposed to a temperature of 15° Reau- mur during twenty-four hours, readily fermented, and afforded a considerable quantity of carbonic acid gas. After the fermentation was over, the whole being submitted to distillation yielded ten ounces of a spirituous liquid. Such were the chief methods employed by MM. Nicolas and Gueudeville, with the view of establishing the peculiar nature of diabetic urine. Dr. Bostock also submitted portions of diabetic urine to the action of different re-agents. His experiments, as well as those of Cruikshank, Nicolas, and Gueude- ville, satisfactorily prove that the different salts exist in diabetic urine, nearly in the same propor- tion to each other as in the healthy state of the fluid, but that they amount only to about one- third of the absolute quantity. Sometimes dia- j betic urine has been found to contain a small por- tion of blood, (as in the case of Stevenson, related by Dr. Watt,) and occasionally a white milky- 616 DIABETES. like fluid resembling chyle. Having thus noticed the principal circumstances connected with the urine in diabetes, it may be proper to allude to the state of the blood in that disease. Analysis of the Blood in Diabetes.—Nico- las and Gueudeville, Wollaston, Marcet, Henry, and some other eminent chemists, have performed many experiments to determine the existence or non-existence of sugar in the blood of persons labouring under diabetes mellitus. Dr. Rollo stated (in the case of Captain Meredith) that the patient was bled, and the blood was kept for seve- ral months without undergoing any putrefactive process; while a portion of healthy blood, taken at the same time and placed in the same room, exhibited evident marks of considerable putrefac- tion in four days, and was obliged to be thrown away on the seventh. Nicolas and Gueudeville ascertained that the blood of diabetic patients afforded some serum, a small quantity of fibrine, and was less animalized than that of persons in good health, but that it contained no saccharine matter. Having satisfied himself how the albu- minous part of healthy serum could be most com- pletely coagulated, and by what appearances the presence of sugar that had been added to it would be most easily discerned, Dr. Wollaston added half a drachm of muriatic acid, previously diluted with one drachm and a half of water, to six drachms of serum, and immersed the phial con- taining them in boiling water during four minutes. In the course of a few hours a drachm or more of water exuded from the serum that had been so coagulated. A drop of this water being evapo- rated, the salts which it contained were found to crystallize, so that the forms of the crystals could be easily distinguished; they were principally common salt. If any portion of saccharine mat- ter were added to the serum previous to coagula- tion, the crystallization of the salt was impeded, or wholly prevented, according to the quantity of sugar present. By the addition of ten grains to the ounce, the crystallization of the salts was en- tirely prevented, and the degree of blackness and disposition to deliquesce was of course more mani- fest than with smaller quantities. As a further test of the absence or presence of sugar, Dr. Wol- laston added a little' nitric acid to the salts that remained after crystallization of the drop. He found that when the serum had been successfully coagulated without any addition of sugar, the nitric acid merely converted the muriatic salts into nitrates, and nitrate of soda was seen to crys- tallize without foam or blackness. But when sugar had been added, a white foam rose round the margin of the drop, and if further heat were applied it became black, in proportion to the quan- tity of sugar present. On applying the above tests to diabetic blood and serum, Dr. Wollaston failed to detect any traces of sugar. Dr. Henry performed some interesting experiments on dia- betic blood, as noticed by Dr. Ferriar, which con- firm the results of Dr. Wollaston's analysis. Dr. Prout has also made a comparative examination of the blood of a person labouring under con- firmed diabetes, with healthy blood. He states that he was induced to undertake it with the intention principally of determining whether the quantity of azote was the same in each. The diabetic blood presented the usual appearances of healthy blood. The following were the results of his ex- periments :— Specific gravity of the serum of diabetic blood.............. 1029-5 ---------------of the urine of the same person, voided at the same time........... 1044*8 One hundred grains of the diabetic serum, eva- porated and dried to the standard formerly men- tioned, left ten grains of solid matters, which upon analysis were found to consist of albu- men............................... 8-7 Lactates and animal matters usually existing in the blood........................ -6 Salts................................ -7 10. " Which very nearly coincide," says Dr. Prout, " with the proportions ascertained by Dr. Marcet and Berzelius to exist in the serum of healthy blood. One hundred grains of the diabetic urine, evaporated and dried as before, left 11-7 grains, nearly the whole of which was sugar. Portions of albumen from the serum of this diabetic blood, dried and analysed as before, yielded precisely the same results as albumen from the serum of healthy blood."—" To ascertain," Dr. Prout continues, " the relative proportions of azote present in the diabetic urinous extract and the extract from healthy urine, portions of them were burnt with the oxide of copper. The results were, that one hundred parts of the diabetic extract (abstracting alkaline and earthy salts) yielded only 6-5 parts of azote, while the same quantity of extract from healthy urine yielded from thirty-five to forty parts of the same principle. To obviate the objection that the saccharine matter of the urine might be formed from the other principles of the blood and not from the serum, comparative experiments were made with the cruor of healthy and of diabetic blood. The results were precisely similar as to the quantity of azote in both, and at the same time the quantity of azote did not differ much from that found to exist in the serum above men- tioned." From these experiments of Dr. Prout's, it may be safely inferred that the blood of diabetic patients contains an equal quantity of azote with that of healthy persons. We may observe here, that Dr. Wollaston thought that, in order to account for the presence of sugar in the urine, we must either suppose a power in the kidneys of forming this new product by secretion, or—if we admit that the sugar is formed in the stomach by a process of imperfect assimilation, — must then allow the existence of some channel of conveyance from the stomach to the bladder without passing through the general system of blood-vessels. He conceived, that if prussiate of potass could be taken with safety, its presence would be discerned by a solution of iron in as small a proportion as almost any known chemical test. Finding that a solution of this substance might be taken without the least incon- venience, and that in less than one hour and a half the urine became perceptibly impregnated with it, although the quantity employed had not amounted to more than three grains of the salt, DIABETES. 617 he administered to a healthy person, about thirty- four years of age, a dose corresponding to three grains and a half of the dry salt, and repeated it every hour to the third time. The urine being examined every half hour, was found in two hours to be tinged, and to afford a deep blue colour at ! the end of four hours. Blood was then taken from the arm, and the coagulum, after it had formed, was allowed to contract so that the serum might be fully separated. He then endeavoured to ascertain the presence of the prussiate by means of a solution of iron, but without effect. Dr. Marcet also performed several interesting experi- ments at the request of Dr. Wollaston on this point. In one experiment he administered five grains of prussiate of potash dissolved in water, to a young woman labouring under diabetes melli- tus ; and the proportion was repeated every hour till she had taken thirteen or fourteen such doses. After the fifth dose, her urine, by the addition of a drop or two of a solution of sulphate of iron, turned blue instantly. At this period of the ex- periment, a blister was applied to her stomach, and after a few hours, whilst still taking the prus- siate of potash, and whilst the urine strongly indi- cated its presence, the blister was cut and the serum collected. This serous fluid being, in the same manner as the urine, subjected to the action of a solution of sulphate of iron, did not suffer any change of colour in the least indicative of the presence of prussic acid. Yet the urine still remained capable of imparting a blue colour to solution of iron, fifteen hours after taking the last dose of the prussiate of potash. Dr. Marcet afterwards repeated Dr. Wollaston's experiments on the serum itself, and with a similar result. He also found that the susceptibility of the passage by which prussiate of potash is transmitted to the bladder seems to vary in different individuals ; for in five trials he failed to discover any vestige of that salt in the urine of persons who had taken it in quantities sufficient to produce its appearance in others. These experiments, though highly interesting and ingenious, still fail to establish the fact of a direct communication between the digestive organs and the kidneys or bladder, by which sugar may be conveyed from the former to the latter without its entering the general circulation. It is known that other substances are also met with in the urine, such as urea and lithic acid, which have never been detected in the blood or other fluids of the body. We have ourselves also carefully analysed the blood taken from several diabetic patients, but never could detect the existence of sugar in it, nor indeed any marked difference in its chemical composition from blood in the healthy state. Hence, it may be concluded that saccharine matter does not exist ready formed in the serum of diabetic blood ; unless, indeed, we suppose with- some modern Continental writers, that sugar, like mercury, upon entering the blood, unites itself in- timately with the albumen, and constitutes a new compound of unknown properties, and which con- sequently sets our tests at defiance, although easily decomposed by the glands, of which organs this species of separation seems the natural office. It is not more difficult to conceive how a kidney Vol. I___78 3b* strongly excited by a redundant efflux of blood to' its tissue, should convert part of the elements of the latter into sugar, than that the mammary glands of a woman should be found to perform the same thing in the sugar of the milk which it secretes upon a similarly sudden determination of blood to it after parturition. [This negative evidence has been suffered to prevail with the generality of pathologists, al- though it had been observed that the fluid of trans- piration was sweet. Recently, too, as before ob- served, saccharine matter has been detected in the saliva. It is clear, therefore, that the blood whence these secretions are formed must contain sugar or the elements whence it was formed. Of late, however, respectable chemists have affirmed, that they have unequivocally discovered saccha- rine matter in the blood. To obtain diabetic sugar, the serum was coagulated by Mr. M'Grc- gor, and carefully dried by heat. The solid mass being divided as minutely as possible by a pair of scissors, was boiled in water, and the decoction having been filtered through paper was evapo- rated to a certain extent The concentrated liquid, on the addition of yeast, fermented strongly for several hours. Not satisfied with these re- sults, and desirous of tracing the presence of sac- charine matter still farther back, Mr. M'Gregor instituted several experiments, from which he is led to infer, that the stomach in diabetes, forms a preternatural proportion of sugar, and that the admission of the saccharine matter into the chyli- ferous vessels, and the consequent presence of a material in the blood, which is foreign to ite healthy composition, is the cause of the different morbid phenomena of diabetes;—the kidney merely separating—as the great depuratory organ—the foreign material conveyed to it from the blood. Pathology of Diabetes. — It is matter of regret, that hitherto the most careful anatomical research has afforded no satisfactory information concerning the origin of this complicated malady. Various morbid changes have'been detected on the post-mortem examinations of diabetic patients, but these, in not a few instances, may more pro- perly be considered as the effects than as the causes of the disease. The kidneys are more fre- quently met with in a morbid state than any of the other abdominal viscera; their size is occa- sionally much augmented. In four fatal cases under our own observation in immediate succes- sion, these organs were greatly enlarged, and the ureters were considerably dilated. Dr. Duncan has related a case of diabetes in the Edinburgh Clinical Reports, in which the kidneys were much larger than common -, and Dr. Rutherford and other pathologists have noticed an unnatural in- crease of their size. The texture of the kidneys in some instances is firmer, in others more flaccid than usual; their vessels are also occasionally preternaturally enlarged; and their surrounding cellular membrane has more than once been found filled with a gelatinous substance. In the case of Robinson, mentioned by Dr. Rutherford, the kidneys were much augmented in bulk, soft, and their surfaces painted with numerous vessels; the vessels were uncommonly dilated. The emulgent vein of the right side was not under three-fourths 618 DIABETES. of an inch in diameter, as it appeared distended with blood. The ureters also were considerably dilated ; the bladder seemed capacious, its coats thickened, and it was half filled with liquid. In the dissection, too, of Ann Laidlow, given by the same author, the kidneys were found somewhat enlarged, and on cutting into them the tubuli uriniferi were more distinct than usual, and the pelvis of each was also considerably increased ; but no other morbid change of structure was per- ceived. Mr. [Sir B.] Brodie, on examining the kidneys of a patient of Dr. Warren's, who died of diabetes, found them to possess an unusually firm and grisly texture. In order to ascertain the state of the blood-vessels, he injected one of the kid- neys with size and vermilion previously to exa- mination ; the other was allowed to remain in its natural state. On cutting into the substance of the injected kidney, the cortical part appeared unusually red, and the cryptae were seen more numerous, larger, and more distinct than ever occurs under circumstances of the most fortunate injection. The blood-vessels of the cortical sub- stance of the kidney which had not been injected were unusually turgid; the ureters, emulgent artery, and vein, were of natural dimensions; the renal capsules were firmer and harder in their texture than usual, and seemed to partake of the grisly structure of the kidneys : the bladdder was sound. M. Dezeimeris noticed the increased bulk of the kidneys in three cases of diabetes, which occurred at the Hotel Dieu in one year. " In all the cases the volume of the kidneys was much enlarged; all their vessels were considerably de- veloped, and their tissue, which was gorged with blood, and of a deep red colour, could be torn with the greatest facility." It appears from an interesting and extremely minute examination of a case of diabetes conducted by Dr. Monro, that all the glands of the absorbent system were either enlarged or morbidly altered in structure. Upon dividing the right kidney into two equal portions by a longitudinal incision, it seemed as if it had been very successfully injected. Many blood- vessels, both in the cortical and medullary part, were filled with florid blood, owing to which the distinction between these parts was not well de- fined. A transparent yellow-coloured substance was found effused on the outer side of the pelvis and infundibula. Dr. Beer met with a very remarkable degenera- tion of both kidneys in the body of a young man, who had for a long time laboured under diabetes. They were extended by hydatids, contained in their interior substance, to such an enormous size that each was one foot long and seven inches broad, and the ureters were of the size of the thumb. The ureters and bladder are sometimes con- siderably dilated. In one instance, Dr. Duncan found the bladder capable of containing five pounds of urine, and he states that about that quantity remained in it after death. It had its natural form, and its parietes were rather thinner than usual, although the muscular fasciculi were very well marked. Its inner coat presented a per- fectly healthy appearance, and the ureters were about one-fourth of an inch in diameter: the sym- pathetic and splanchnic nerves were also enlarged to nearly three or four times their usual size. In the dissection of a diabetic patient of Dr. Pear- son's, mentioned in Dr. Rollo's work, the kidneys were found to be in a perfectly sound state, and so were the ureters; but the urinary bladder was much thickened, and the urethra was dilated to three or four times its usual width; in another, related by Dr. Marshall, the kidneys had assumed a chocolate colour, were large, and the texture soft and flaccid, particularly that of the portion comprehending the tubuli uriniferi: the bladder exhibited nothing unusual. In the case of Oliver Ormrod, detailed by Dr. Clark, the ureters were very much dilated, and through their whole course measured full half an inch in diameter. In two cases, we have found the bladder much contracted and thickened. In one instance the capacity of this viscus was so much diminished as not to ad- mit more than a small egg; in the other, the parietes of the bladder were even more thickened. As post-mortem examinations in cases of death from this disease are always interesting, we shall detail the following one which recently occurred in our own practice. The external cutaneous veins were distended with fluid blood. On de- taching the scalp, some ounces of blood issued from the cut surface ; the pericranium was redder than usual. The encephalon, and its containing membranes, appeared free from disease. On rais- ing the sternum from the pleura, there were ex- hibited no traces of recent inflammation, but exu- dations of coagulable lymph appeared on the sur- face of the pleura pulmonalis, which had formed pretty strong bands or partial adhesions to the pleura costalis, particularly on the right side. Lungs sound. Nine ounces of fluid were found in the right cavity of the thorax, and eight ounces in the left; the quantity of liquor pericardii was about half an ounce. Gall-bladder distended with bile. Liver larger than usual, and of a firmer consistence. Spleen of natural size, though rather denser than common. The urinary bladder was full. The left kidney had undergone a remark- able diminution in bulk, being not more than one- third of its usual size. After the removal of fat, &c. it weighed ten drachms (troy weight) ; it was otherwise healthy, with the exception of some small hydatids on its surface. The right kidney weighed five ounces six drachms (troy weight); its surface was a little irregular. The stomach was inflamed on its posterior side and next the cardia ; the inflammation only affected the inner membrane, which was also slightly corroded by the gastric juice. It contained five ounces of half digested cream-like fluid. In this instance, the diminished size of the left kidney formed the most singular feature in the dissection. MM. Dupuytren and Thenard, on the examina- tion of a diabetic patient, met with the stomach in a very much enlarged state: its vessels were greatly dilated, and forming upon the internal membrane of the organ a red net-work. It also contained a considerable quantity of uninflamma- ble gas, and a small portion of a greyish liquid, in which were floating seven or eight small, yellow ish, round, fatty substances. The duodenum, and upper part of the jejunum and ileum, were some- what redder and thicker than natural; no appear- ance of disease was discoverable in any other part DIABETES. 619 of the intestinal canal. The liver, spleen, and pancreas were sound. The gall-bladder was moderately filled with healthy bile. The kidneys were at least one-third larger than usual; their structure was soft and of a grey colour, but in every other respect natural. The other organs connected with the urinary apparatus were free from disease, though the bladder was very small. The abdominal lymphatic system, and the tho- racic duct, were more than ordinarily developed. The arterial and venous systems had undergone no morbid alteration. The lungs adhered to the sides of the chest by loose cellular tissue. In the right lung there were some small vomicje contain- ing pus; in the left, several cysts completely filled with an elastic fluid. The muscles were pale and flaccid, but otherwise in structure quite healthy. Dr. Baillie has also left an account of the post- mortem examination of a person who had been long affected with diabetes, and had been a patient under his care in St. George's Hospital. The state of the kidneys is very minutely noticed. " Both were of the ordinary size and shape. When the proper capsule was removed from each, the veins on the surface were much fuller of blood than usual, and had an arborescent appearance. When the substance of both kidneys was cut into, it was observed to be every where much more crowded with blood-vessels than in a natural state, so as in some parts to approach to the appearance of inflammation. Both kidneys had the same degree of firmness to the touch as when healthy, but they were hardly so firm as kidneys usually are the vessels of which are so much filled with blood. A very small quantity of whitish fluid, a good deal resembling pus, was squeezed out from one or two of the infundibula in both kidneys, but there was no appearance of ulceration in either. The artery and vein passing into the cavity of each kidney presented exactly the natural appear- ance. After separating, a good deal, the cellular membrane which joins together the blood-vessels, was discovered a lymphatic passing from one of the kidneys : it was of the usual size, had the common valvular appearance, and was empty. There were doubtless several others belonging to both kidneys, but they were so small as not to be distinguishable. The nerves of the kidneys were of the usual size, and the ureters of both were per- fectly natural. The renal capsules appeared quite healthy. The structure of the liver, stomach, spleen, pancreas, intestines, and urinary bladder, was perfectly natural, but one or two of the me- senteric glands contained a considerable quantity of earthy matter." Organic changes are sometimes discovered in the internal structure of the kidneys in diabetes. We may state .as a pathological fact of some im- portance, that in three instances of this disease we have detected the peculiar granulated or mot- tled condition of these organs, so well described by Dr. Bright as occurring in dropsical affections accompanied with albuminous urine. The cortical part had lost ail appearance of its natural struc- ture, and presented a tolerably uniform yellowish colour with many yellowish-grey spots. The me- senteric glands in two cases were much enlarged 'and indurated; and in the other, several vomica? were detected in the right lung. There was no evidence of organic disease in the liveT or in any of the other abdominal viscera in the latter in- stance. Besides these morbid conditions of the kidneys and their appendages, a diseased state of the sto- mach and lungs has also been noticed in this affection. The former organ has been found to exhibit marks of inflammation, and the latter have been studded with tubercles in different stages of their progress. In a fatal case of diabetes, which occurred in the Manchester hospital a few months since, both lungs were tuberculated; and except dilatation of the pelvis of the kidneys and of the ureters, there was no perceptible disease of the urinary organs. The pulmonary affection was subsequent to the diabetes, therefore it cannot be said that this affection was excited by the former. In most of the dissections on record, the mesen- teric glands have afforded evidence of structural derangement; and from our own observation we should say, that next to the enlarged and flaccid state of the kidneys, this is the most uniform morbid appearance in diabetes. We not unfre- quently meet with similar disease of structure, however, in diseases very different both in their nature and symptoms from the one under consi- deration ; hence, it is not singular that such an infinity of hypotheses should have been advanced to account for the phenomena of this malady. In some examinations of diabetic patients no trace of organic disease has been discoverable. An in- telligent practitioner informed us during the last year, that he had recently examined the body of a young man, twenty-one years of age, who had died of this disease, without being able to detect the least deviation from healthy structure in any of the cavities.* The different morbid appear- ances in the stomach, liver, and lungs, noticed above, are undoubtedly in some instances merely accidental attendants ; and indeed the diseased state of the kidneys themselves is, we conceive, mostly the consequence of long-continued morbid action. The ureters, too, become dilated, and the bladder contracted and thickened, from the con- stant passage of such an increased quantity of urine. From these observations, it is evident that the information regarding the nature of diabetes derived from dissection is very unsatisfactory, and that up to the present period we are ignorant of the essential pathology of the disease. With so defective a pathology, the treatment must neces- sarily be vague, and in a great measure empirical. The Treatment of diabetes mellitus comes now under consideration. The statements respect- ing the cure of diabetes furnished by the ancient writers on this disease are altogether unsatisfac- tory. This cannot be matter of surprise when it is considered that they regarded only the unnatural quantity of the urinary discharge, being entirely ignorant of any morbid alteration in its qualities. As it would answer no useful purpose either to enter into an examination of the comparative value of the whole of the modes of treatment that have been proposed, or to dwell at any length upon the * In a dissection of a diabetic patient of Dr. Forbes, no morbid lesion could be detected except slight enlarge- ment of the kidneys, and a remarkably hypnrtrophied state of the duodenum. It was simply hypertrophy, without any mark of inflammation or alteration of tissue. 620 DIABETES. particular remedies which have been recommend- ed, on various authority, for ite removal, we shall first merely notice the four branches of cure, ani- mal diet, venesection, opium, and astringents, which of late years have been chiefly adopted ; and then point out those principles of treatment which seem to us to be best calculated to arrest the progress and remove the symptoms of the compla nt. Dr. Home first suggested the employ- j ment of animal diet and alkalies, with a view to j their specific operation as septics ; but Dr. Rollo j is entitled to the high merit of having put into ! practice the rigid use of an animal regimen as the most effectual mode of curing diabetes. The em- ployment of this plan is founded on the principle of preventing the introduction of the materials of which sugar is formed into the system, and of thus destroying the saccharine impregnation of the urine. Dr. Rollo also combined with an entire j abstinence from vegetable food the exhibition of i the hepatized ammonia, and the occasional inter- ] position of narcotics and emetics. Dr. Rollo's practice has long since enjoyed a fair trial in the | hands of many distinguished practitioners, and consequently sufficient time has been allowed to admit of a porrect inference being drawn respect- ing its real claims to the high character bestowed upon it by so able an advocate. Without particu- larising individual cases in support of the efficacy of a strict adherence to animal food in removing some of the more formidable symptoms of diabetes, it may be stated that its power of abating thirst, diminishing the unnatural quantity of the urinary secretion and rendering it more animalized, of relaxing the skin, and of increasing the bulk and strength of the body, rests on the incontrovertible evidence of facts and experience. Its influence upon the urine is in general speedy and favourable, and though perhaps when employed singly it may prove on some occasions inadequate to the perfect cure of the disease, still, under almost all circum- stances, it will be found to act as a powerful auxiliary to venesection, opium, or the other means which may be adopted. Dupuytren and Thenard have contended that diabetes may be as readily subdued by animal diet as an intermittent by the use of the cinchona bark. Dr. Baillie, in alluding to Dr. Rollo's method of practice, ob- serves that it has been much more successful than any other hitherto adopted. Dr. Bardsley has also shown the advantages derived from confining diabetic patients to animal food. Several of his cases strongly exemplify the reduction in the quantity of the urinary secretion, and the disap- pearance of its saccharine properties, which speedily followed the use of this regimen. Dr. Willan states that this disease has been relieved, and the saccharine quality of the urine Temoved, by animal diet and the general plan recommended by Dr. Rollo. Were it necessary, other respectable authorities might be adduced in support of the curative value of the same method. We have adopted the animal regimen in several instances with the most marked and unequivocal benefit, and have known patients, who have had sufficient means and resolution to persevere in its use for some length of time, not merely to recover their wonted health, but overcome the tendency to the disease. Owing to the high price of meat, but few of the poorer classes of persons who have the misfortune to labour under this complaint are capable of a strict compliance with this plan of treatment, for the amount of their vlaily labour is mostly insufficient to procure such a supply as the appetite demands. This is not the only ob- stacle to the employment of animal food as a remedy in diabetes; for there is often considerable difficulty in keeping the patients for any length of time exclusively confined to such a regimen; and many failures with this method of treatment may be attributed to a secret indulgence in variety of aliment In some instances there is an insu- perable disgust at the taste, smell, and even sight of animal food. With the ordinary class of hos- pital patients it is extremely difficult to prevent a deviation from the prescribed plan of diet Dr. Rollo himself laments that the mode of cure which he proposed is so contrary to the inclinations of the sick. " Though perfectly aware," he observes, " of the efficacy of the regimen, and the impro- priety of deviations, they commonly trespass, con- cealing what they feel as a transgression to them- selves. They express a regret that a medicine could not be discovered, however nauseous and distasteful, which would supersede the necessity of any restriction of diet." This aversion, how- ever, to the animal regimen is by no means gene- ral, for in some instances it has been adopted with little or no inconvenience, and even been continued by the patients from choice, when a certain allow- ance of vegetable food has been permitted by the physician. Dr. Marsh rather overrates the loathing of animal food on the part of diabetic patients, when he asserts that the adoption of the animal regimen, during even fourteen days, is, in his opinion, more than questionable. In some of the cases published by Dr. Bardsley, the exclusive use of animal food was continued for more than two months. We occasionally visit a lady who has laboured under diabetic symptoms for more than nine years, and during the greater part of that time she has adhered, with scrupulous exactness, to the use of animal food. It must be recollected, however, that there is a certain period at which it is necessary to combine vegetable with animal diet. When the more ur- gent and characteristic symptoms of the disease are subdued, and at the same time the strength I and bulk rather diminished than increased, and I the appetite is feeble and impaired, it is proper to ! allow a small proportion of vegetable food. The salutary effects of this change are soon rendered ; visible in the improvement of the appetite, and the acquisition of flesh, strength, and spirits. It has been remarked, also, that whenever a return to vegetable diet is allowed not only with impu- i nity but advantage, it forms the surest criterion of the restoration of the assimilating powers of i the system, and consequently of the removal of | the disease. It is necessary, however, to caution patients against indulging too freely at first in the use of vegetable diet after a long and rigid adherence to animal food, as they are apt, from the agreeable nature of the change, to relinquish the latter regimen altogether, and thus favour a reproduction of the disease. At this stage, the state of the digestive organs requires particular attention in order to establish on a firm footing DIABETES. 621 the benefit obtained ; for if the stomach and bow- els are permitted to become deranged by irregu- larities in diet, the danger of a relapse may be apprehended. Bitter tonics, mild aperients, chiefly rhubarb and magnesia, and sea air, prove emi- nently useful in promoting the tone of the sys- tem. It is by no means intended to recommend animal diet as the only mode of subduing this obstinate disease, but to show that no other, with- out its aid, will have the same influence in arrest- ing the progress of the diabetic symptoms. Previously to commencing with the sole use of animal food, it is of the first importance to have the stomach and bowels brought into as natural a state as the character of the complaint will allow. Costiveness must be obviated by the regular use of mild aperients, and for this purpose castor oil is preferable to the saline class of pur- gatives. The first effects of this plan of treat- ment should be very carefully watched, as there is considerable risk of the sudden occurrence of acute inflammation of the thoracic or abdominal viscera when it is adopted shortly after an entire abstinence from vegetable food. We have more than once been obliged to modify the practice on this account. The liability to inflammation under the animal regimen is strikingly exemplified in the case of James Ridens, aged 26, who was ad- mitted into the Manchester hospital on the 2d of August, 1824, labouring under the ordinary symp- toms of diabetes. The quantity of urine passed in the twenty-four hours amounted to nearly two gallons. One pint yielded, on evaporation, 1 oz. 4 drs. and 8 grs. of a thick sweet syrup. He had lost all venereal appetite, and his semen was in- voluntarily discharged. Animal diet was pre- scribed, and the nitric acid mixture was ordered for common beverage. His bowels were opened by the aid of castor oil. On the 5th the urine was diminished more than four pints, and the pa- tient said that it was somewhat less sweet to the taste. He had no aversion to animal food. Early on the 8th he was suddenly seized with a severe pain in the epigastric region, which was much ■ggravated under the pressure of the hand. The stomach rejected every substance received into it. The pulse was small and frequent, and the coun- tenance indicated great uneasiness. Twenty leeches were instantly applied to the epigastrium, sixteen ounces of blood were removed from the arm, and a purgative enema was injected. In the evening the patient seemed somewhat relieved by the bleeding, but the pain of the epigastrium was still present. A copious evacuation followed the enema. The serum of the blood was milky, and the crassamentum firm. Pulse 120, and weak. A vein was again opened, and eighteen ounces of blood were abstracted; twelve leeches were applied to the epigastrium, and a pill with two grains of calomel, and two of extract of hyoscy- amus, was directed to be taken every third hour. The pulse after the bleeding was 106. On the morning of the 9th, we found the patient much worse, and evidently sinking very rapidly. He could with difficulty reply to the questions put to him. The pain of epigastrium was diminished, but the pulse was tremulous and intermitting, and his extremities were cold. His bowels had been moved twice during the night Anodyne fomen- | tations were applied to the epigastrium, weak wine and water was administered, and bottles of hot water were applied to the feet. He expired in the course of the afternoon. His friends, though urged by frequent solicitations, obstinately refused to allow an inspection of the body. From the above reports, however, it is highly probable that Ridens died of inflammation of the stomach, induced by an unlimited use of animal food. At first, it was imagined that the sudden attack which proved fatal might have been owing to over-reple- tion ; but he had retired to rest as well as usual, and even complained of severe pain of epigas- trium before breakfast, which was generally with him a very hearty meal. In the case, too, of John M'Lean, related by Dr. Cleghorn, it appears that, although his diabetic symptoms were much re- lieved by the use of animal food, still the pneu- monia which destroyed him was induced by strict adherence to this regimen. It may be remarked here, that M. Rochoux pre- scribed urea to a diabetic patient, (whose blood i was analyzed by MM. Vauquelin and Segalas without finding in it any trace of sugar,) and it was continued for several days; but the urine, which was increased in quantity, afforded, on careful chemical examination, no urea. Very opposite to the above plan of treatment recommended by Dr. Rollo, is that of depletion, by copious and repeated bleedings. Dr. Watt was first led to try venesection from the circum- stance of his patient expectorating blood, and from having in mind the case of Captain Mere- dith, (related by Dr. Rollo,) who, on the evening after bloodletting, " felt lighter, cooler, and more cheerful, and had less pain about the kidneys." On the following day Dr. Watt's patient seemed much relieved, the quantity of urine had dimin- ished, the crassamentum of the blood was black, and void of tenacity. Finding so much relief from the first bleeding, he resolved on a second, and eighteen ounces were accordingly taken from the arm ; an animal diet was enjoined, and car- bonate of ammonia prescribed to obviate acidity. By repeated bleedings and a similar diet and medi- cines, in about four months this patient was re- stored to health. The following is the statement of Dr. Watt's mode of treatment. " The treat- ment according to my plan is to reduce the quan- I tity of blood already in the system, to diminish the supply of new materials, and to afford a cer- tain proportion of stimuli. The first is accom- plished by venesection; the second, by absti- nence ; the third, by blistering, mercury, &c. The effect of this treatment on the system is increased re-action, indicated by some degree of fever, and terminating in the restoration of all the secre- tions." It is to be regretted that the same result has not attended the employment of bleeding in cases of diabetes occurring to other practitioners. Dr. Watt appears to have tried venesection in one or two instances under the most untoward circumstances, the pulse being slow and feeble, the strength reduced, and the lower extremities oedematous; and still with benefit. Even the first bleeding sometimes produced an evident im- provement in the symptoms. In the case of Ste- venson, the fifth bleeding acted like a charm. " The recovery after this was instantaneous and 622 DIABETES. striking. The painful sensation in his bowels left him; the power of virility returned ; the gums became sound; the skin soft and perspira- ble ; the saliva, the urine, and the alvine discharge natural; in six days he returned to his work : in two months he was restored to his original health." Dr. Watt found that the blood first drawn in diabetes was thin and destitute of buffy coat; the coagulum being so soft and weak that it could not support its own weight. As the operation was repeated, the blood assumed more and more an inflammatory character, and often exhibited ulti- mately a thick buffy coat, and a strong, firm, and tenacious crassamentum. "The improved textgre of the blood," he observes, " as venesection was repeated, the increased hilarity of mind, and gene- ral renovation of the living functions, warrant the conclusion, that, however weakening it may be in particular circumstances, bloodletting is a most important mean of disburdening the system, and of preparing the way for the final re-establishment of health and vigour." Mr. Murray has also related a case in the eighth volume of the Edin- burgh Medical and Surgical Journal, in which the blood improved simultaneously with the health. Some other instances have been recorded, illustra- tive of the salutary change produced in the con- stitution of the blood itself by repeated venesec- tions. Dr. Ayre found bleeding useful in one example of this disease. The appearances of the blood strongly resembled those observed by Dr. Watt; and indeed, so close was the relation betwixt the state of the blood and the relief afforded, that the amount of the one was almost determinable by a view of the other. It is men- tioned that during the first month the patient lost eighty-eight ounces of blood, and took at least only half the usual food, yet he gained nine pounds in weight, and acquired sufficient strength to follow a laborious employment. The marked good effects of venesection in two cases of diabetes have been ably shown by Dr. Satterly. His ex- perience fully confirms the safety and efficacy of the practice in some species of that complaint. We are enabled to speak of the real value of venesection in diabetes from a careful and fair trial of its influence upon the symptoms on several occasions. It is a remedy of the first importance during the acute stage of the disease, for it has the power of abating the thirst, reducing the quantity of the urinary discharge, and restoring the natural secretion of the skin. Under no other circumstances have we employed venesection with advantage, though blood has been abstracted from the system at regular intervals and to a considera- ble amount. The practice, indeed, on the contrary, has been uttended with a diminution of the pa- tient's strength without relief to the diabetic symptoms. Taking Dr. Watt for our guide, we have followed his plan of treatment with scrupu- lous exactness, with a view of determining its true claims to confidence, but we have had too often to lament the want of success which has followed its adoption. The experience of the profession at large would seem to confirm the statement just made ; for the practice of venesec- tion, so generally employed shortly after Dr. Watt's publication, is now, comparatively speak- ing, only partially pursued. We venture to re- commend the employment of bloodletting during the early stages of the disease in persons of somewhat plethoric habit; and where the strength is not much reduced, and particularly when pul- monary irritation, as indicated by difficulty of breathing, slight cough, and shooting pains in the chest, may be present The propriety of repeating the operation, and the frequency of the repetition, will be best determined by the effects produced upon the symptoms; for in some instances it may not be prudent to open a vein more than once, whereas in others no such restraint is necessary. There is sometimes an objection on the part of the patients to allow a fair trial of venesection, for feeling great debility and lassitude on the least exertion, they complain more of the want of a supply than of a superabundance of blood, and thus cannot be convinced of the benefit likely to accrue from such practice. When general bleeding cannot with safety be adopted, the local abstraction of blood may occa- sionally be substituted with advantage. It has been our uniform custom in cases of this disease, to direct the application of leeches to the loins, when much pain and uneasiness have been expe- rienced in the region of the kidneys, and always with good effect; and we have also found, with Dr. Marsh, that leeches on the epigastrium have been highly useful in removing the feeling of in- ternal heat and tenderness so much complained of in that part. Indeed, patients have requested the repetition of leeches to the epigastrium on more than one occasion, being fully convinced of the benefit derived from them. This local bleeding has not materially reduced the strength, even when employed more than once. It should never be omitted under the circumstances we have pointed out, for though possessed of no curative efficacy, it is valuable in relieving painful and unpleasant symptoms, and is seldom, if ever, attended with harm, which is more than can be truly said of some other remedies proposed in this disease. In a case of diabetes, under the care of Dr. Forbes, the first application of leeches to the epi- gastrium was immediately followed by a change in the urine to the healthy appearance. It was also much diminished in quantity. But the benefit was temporary, and although the same effect fol- lowed subsequent leechings, but in a less degree, the general result did not seem very beneficial. Cupping is preferable to leeches when it is desirable to fix the precise quantity of blood to be removed, on account of the weakened state of the patient. Great benefit sometimes attends the ap- plication of blisters to the loins in cases of this disease. We have preferred the frequent repeti- tion of blisters, to keeping the excoriated surfaces open by means of irritating dressings. With the view of diminishing the nervous irri- tability of the system so generally present in this disease, the narcotic power of opium has been freely tried, and in many instances much benefit has attended its exhibition. It has also been pre- scribed with the intention of opening the skin, and exerting an astringent effect upon the kidneys, similar to that which it usually induces on the intestinal canal. Dr. Warren published two cases DIABETES. 623 of diabetes mellitus treated with opium, in the fourth volume of the Medical Transactions, which afford satisfactory evidence of the influence of that valuable drug in restraining the quantity, and moderating or removing the saccharine quality of the urine. In one of the patients this desira- ble effect was produced after gradually increasing the proportion of opium to six grains twice a day; the sweetness of the urine returned on the diminution of the dose, but was again removed by increasing it. The other patient died, (although the original disease was subdued,) of phthisis pulmonalis. The dose was gradually augment- ed to five grains of solid opium four times a day. Dr. Elliotson has since exhibited opium in four cases of diabetes, in which the good effects of this remedy were satisfactorily established. He has administered it in large doses, but it appears more advisable not to push the quantity to any great extent. Dr. Prout also found opium useful in this affection. " All the beneficial effects," he ob- serves, " to be really expected from opium, may in most instances be obtained by moderate doses only ; and when thus judiciously exhibited, and when no peculiarity of constitution forbids its use, I believe that it will be found one of the most powerful remedies that we possess in this disease." Dr. Marsh, too, considers, that amongst the reme- dies hitherto employed, opium in very large doses ranks highest, for it possesses the property of checking and restraining the flow of urine, and depriving it of many of its morbid qualities. Our experience accords with that of the above named authors, but we have rarely found it necessary to administer more than six grains in the day, though on some occasions this proportion has been con- siderably exceeded; and when continued, during any length of time, in rather large quantities, this drug has produced alarming and pernicious ef- fects. We are decidedly of opinion, that it proves most beneficial in moderate doses. Of late we have given the preference to the acetate of mor- phia, as it appears to exert an equally powerful influence upon the disease, without occasioning the pain of head and constipation which almost invariably accompany the free exhibition of opium. On the whole, opium is unquestionably entitled to be considered as a remedy of much value in dia- betes, for it not merely diminishes the quantity of the urinary secretion, but also proves useful in removing uneasy sensations and calming mental agitation. Astringents constitute another line of practice which is-very ancient, and is still resorted to by a considerable number of practitioners. They are recommended by Celsus, and from their natural tendency to correct every excess in secre- tion, have obtained considerable notice in the writings of almost every author since his time. That they prove beneficial by constricting the relaxed extreme vessels through which the urine filters into the papilla? of the kidney in diabetes, is the general opinion; but they may probably act also by an inherent sedative power, on which their astringent virtue seems almost entirely to depend. It is sufficiently proved by observation that they lessen the quantity of urine thrown off by the diabetic patient, up to a certain limit; but this they seldom can be made to pass ; and they scarcely ever diminish the saccharine impregnation , of the urine. By acting as tonics, however, and by lessening the sensibility of the stomach, they become useful auxiliaries in several modifications of the disease, and are chiefly objectionable when they are found to increase constipation. Celsus, however, trusted chiefly to a constipating diet.and strong rough wines. Sydenham used the rind of the pomegranate; Morton rhubarb, which was afterwards repeated by Professor Rutherford with advantage. Lime water, decoction of oak baik, infusions of kino and catechu, uva ursi, and di« osma crenata, with many others, have lately been employed with the same intention as the above : but it may be fairly questioned whether alum, the vitriols, or indeed any astringent that ultimately Stimulates, can safely be put in action for the cure of diabetes. Dr. Grahame, of Dalkeith, has lately published an ingenious method of directing the sulphate of zinc to the kidneys, by combining it with turpentine in the form of a pill; but even this mild preparation should be tried with caution. Thus it appears that each of the four modes of cure mentioned above has strong claims to confi- dence and adoption, in certain forms and stages of diabetes. Before laying down what appear to be the correct principles of treatment, it may be proper very briefly to enumerate some of the in- dividual remedies that have been employed for the removal of this disease. The phosphoric acid and its salts, as recommended by Dr. Latham, the phosphate of iron as used by Dr. Venables, in doses of one or two grains, gradually increased to a scruple or half a drachm, three or four times a day ; the phosphate of soda, on the authority of Dr. Sharkey, who has published two cases of cure attending its exhibition ; ammonia ; calcined mag- nesia ; tonics, such as the mineral acids, cinchona, myrrh, &c.; various bitters; mercury pushed to the extent of inducing salivation; chalybeates; cold bathing ; and the colchicum autumnale, have been severally used in diabetic cases, and with various success. We have been informed by an intelligent medical friend, that he has of late ex- hibited the meadow saffron in two instances of this disease, and with a highly satisfactory result; but further evidence of its efficacy is required be- fore it can be entitled to rank as a remedy in dia- betes. Dr. Ferriar has detailed three cases of con- firmed diabetes, in which a cure is said to have been effected by a combination of Peruvian bark, uva ursi, and opium, in the proportion of one scru- ple of each of the former to half a grain of the latter, administered four times daily, with the use of lime water for common drink. He treated this disease as one of debility. A case has also been related by Dr. Bateman, where the same practice was successfully adopted : but the disease return- ed after discontinuing the medicine, and did not so speedily yield to a repetition of it In other hands this treatment has altogether failed. Dr. Shee has published a case, in the progress of which, after the ineffectual administration of as- tringents and opium, paralysis with convulsions of the whole of the right side supervened. In the course of ten days the patient was restored to health, (the diabetic symptoms yielded first, and afterwards the paralysis and spasm,) by a combination of camphor, kino, and oxide of zinc, with tonic infusions. Dr. Alley effected a cure 624 DIABETES. of diabetes by animal diet and cinchona; and Dr. Fraser mentions an instance in which the urine lost its saccharine property in a month after com- mencing the use of animal diet and the sulphate of iron. Of late the aid of iodine has been sought in the treatment of this affection ; and it has been stated to us, on highly respectahle authority, that it is a remedy of superior efficacy to any of the numerous substances that have been proposed for the re- moval of the diabetic symptoms. The experience of the profession, however, is as yet required to establish its real remedial virtues in diabetes. The nitric acid diluted with water, (in the pro- portion of about three drams of acid to three pints of water,) is generally productive of benefit, rniti* gating the thirst and heat, and thereby diminish- ing the quantity of the urinary secretion. In the majority of diabetic, cases it may be taken with advantage ; but when there is any tendency to diarrhoea it ought to be omitted, as the bowels are apt to be disturbed by its use. Under these cir- cumstances, lime water, or soda water, will be found excellent substitutes, as they are palatable to the taste, and quench the thirst. The Bristol water was considered by Dr. Baillie as the best kind of drink in diabetic affections; indeed it has long been celebrated in such com- plaints. Dr. Marsh states that he has known a patient, labouring under confirmed diabetes, drink very largely of the Leamington saline waters without increasing the quantity of his urine, and even apparently with some advantage to his gene- ral health. It has been shown that animal diet, opium, and venesection may be adopted singly with advan- tage in some instances of this disease; but we have found from experience that the conjoint em- ployment of the two former remedies, with the occasional aid of the latter, is attended with much greater benefit. Animal diet forms the first and most important part of the treatment; for it pos- sesses by far the most powerful influence upon the urinary secretion ; and until the unnatural quantity of that fluid be considerably reduced, it is in vain to hope for any material change or im- provement in its quality. Unless the disease be first of all much changed by perseverance in the animal regimen, very little benefit is to be ex- pected from any other remedy whatever. It is proper during its adoption to bear in mind the probable occurrence of inflammation in some or- gan or part of the body, and to be prepared to meet it early by antiphlogistic measures. Opium is also extremely serviceable in allaying nervous irritability, and in restraining the urinary dis- charge. Indeed, few cases of this disease occur, in which the use of this valuable narcotic is not indicated, or can even be omitted without disad- vantage. It does not interfere with the animal regimen, bu' proves a powerful auxiliary in the removal of the complaint. Venesection, too. when employed with vigour during the early and acute stages of the disease, before the constitution has become seriously affected or much debilitated, occasionally arrests the progress of the diabetic symptoms, and sometimes completely subdues the malady. Thus it is obvioubly improper to trust the cure of diabetes to any one remedy. In the selection of remedies, the symptoms form the safest guide. In obscure diseases, of the known varieties of treatment, that is to be held the best from which most benefit has been obtained,- a principle which by no means precludes the trial of new remedies. Having ascertained the individual effects of seve- ral, it is often desirable to employ them together, as by their combined operation they prove more powerful in promoting restoration to health. Though much advantage often attends the united employment of animal diet, opium, and venesec- tion, still we believe that the warm bath will generally be found more useful than the latter mode of cure. This opinion has been confirmed by the experience of several respectable practition- ers. Warm bathing is generally agreeable to the patients themselves, and when aided by flannel clothing proves serviceable in removing the harsh, dry, and shrivelled state of the skin which ac- companies almost every genuine case of diabetes. It may be correctly affirmed, that in every instance of this disease it is of the first importance to em- ploy such means as are best calculated to restore the natural functions of the skin. Our experience entirely coincides with that of Dr. Marsh on this part of the treatment. As early as 1765 " a case of incontinency of urine complicated with diabe- tes" was published in the third volume of the Medical Observations and Inquiries, by Dr. A. Fothergill, of Northampton, illustrative of the good effects of antimonial sudorifics assisted by the warm pediluvium. Under this treatment all the symptoms improved ; the patient's strength and appetite gradually increased ; his skin be- came moist; and his urine was less in quantity than his drink. His recovery was at length per- fect. Dr. Marsh, however, has the merit of hav- ing enjoined a more minute attention to the im- provement of the state of the skin in diabetes. " Medical assistance," as Dr. Watt has justly re- marked, " is seldom required where it is not more or less affected, and we have no security of the disease being removed, though apparently local, till the skin assume a healthy appearance. An excess or deficiency in the cuticular discharge never fails to produce some derangement in the rest of the system." When the functions of the skin are restored, and a free and equable perspira? tion is re-established, a favourable change in the more urgent symptoms soon becomes manifest; the distressing thirst and sensation of internal heat are mitigated, and the quantity of the urinary discharge rapidly decreases. In diabetes, with the exception of the kidney, there is indeed, (as Dr. Bostock observes,) no obvious exit by which the contents of the stomach can be evacuated; the perspiration is checked, the alvine discharge is in general not increased, and the weight of the body is daily diminishing; hence the necessity of directing remedies to the relaxation of the skin. With a view of producing a more direct action on the skin, Dr. Marsh was induced to employ the vapour bath in a well marked case of diabetes placed under his care, and the impression made upon the disease by the frequent use of this re- medy surpassed his expectations. Its salutary effects in promoting diaphoresis were immediately perceptible. He also kept up the perspiration by DIABETES. 625 means of warm clothing and continued bodily Merc.se; and with daily improvement to the patient who was dismissed from the hospital in a convalescent slate. "The warm bath has been «sed, (says the author just named,) " but it has been used only occasionally : it has been employ- ed as a secondary remedy, as one of minor im- portance, and not as one which, if properly man- aged, is of itself sufficient to effect a cure. Its daily employment for weeks, nay months, may be requisite to bring about that relaxed and freely perspiring state of the skin, without which, what- ever temporary abatement in the symptoms, or diminution in the flow of urine, may have taken place, not one step has in reality been made to- ward the accomplishment of a cure." We are satisfied, with Dr. Watt, that it is upon the skin the first impression of disease is generally made, and that we have no security of the system being fully restored till it becomes natural in ite appear- ance, and resumes its functions. In the case of Gosling, already before the public, and in two other instances of subsequent occurrence, we have employed the sulphur in preference to the warm bath, as it possesses the power of stimulating the cutaneous vessels more forcibly than the mere vapour of water. The result on each occasion has been the re-establishment of a healthy cutane- ous discharge with an amelioration of the symp- toms of the complaint. Owing to the great debility and frequent pulmonary irritation present in the disease, much muscular exertion is not practica- ble, though it is particularly desirable to obtain moderate exercise without inducing fatigue. In conjunction with the warm and sulphur baths, the pediluvium, bodily exercise, friction, as recom- mended by Celsus, and flannel clothing, remedies which act directly upon the skin, diaphoretics may be exhibited internally with great advantage. The pulvis ipecacuanha? compositus, in the pro- portion of eight grains every five hours, often suc- ceeds in promoting free perspiration, and also proves useful in allaying nervous irritability. It is certainly entitled to rank very high as a remedy in diabetes. In cases of a chronic kind, and ac- companied by much debility and nervous irritation, Dr. Prout says that he has seen the very best effects from a combination of the pulv. ipecac. comp., and full doses of carbonate of iron, exhibit- ed in the form of an electuary made with the albumen ovi. The tartarized antimony, in the dose of a sixth of a grain every three hours, also determines freely to the skin, and at the same time keeps up a slight degree of nausea, which is rather desirable than otherwise. When the salt acts upon the bowels, the proportion must be di- minished. Having succeeded by these means in re-producing cutaneous secretion, it is indispensa- bly necessary, in order to insure the good effects of the amendment, to avoid sudden changes of temperature, and to endeavour to maintain healthy perspiration by the aid of warm clothing and daily gentle exercise. We are enabled to speak from our own experience of the efficacy of what may be called the diaphoretic plan of treatment. In some instances, where every other means have proved unsuccessful, it has operated in a manner most decidedly beneficial. The patients have re- gained both flesh and strength, and recovered Vol. I. — 79 3 c their wonted spirits and activity. We have found it most advantageous in the incipient state of the disease ; but it has also been of service where the complaint has been long con- tinued, and the patient's constitution much de- bilitated. We are led to draw the following inferences from the preceding facts and observations.— 1st. That no satisfactory explanation of the real nature of diabetes has, as yet, been presented to the pro- fession ; hence, its proximate cause is still in- volved in obscurity. 2d. That it is probable that in most instances the stomach is primarily de- ranged, and that the kidneys are rendered mor- bidly active by the percolation of saccharine mat- ter. 3d. That the employment of an exclusively animal diet proves chiefly useful by cutting off the supply of those materials which lead to the formation of sugar ; and thus, if persevered in for a time, a favourable change mostly occurs in the assimilation. 4th. That the animal regimen, opium, diaphoretics, and the warm bath, con- stitute the most effectual means of arresting the progress of the diabetic symptoms, and of effectu- ally removing the complaint; and that cupping and blistering the region of the kidneys, venesec- tion in recent cases of an acute character, lime- water, or nitric acid for common drink, prove useful auxiliaries to the preceding remedies. 5th. That no individual remedy or method of treat- ment is applicable to every case of the disease: for in some instances an entire abstinence from vegetable food is highly useful; whilst in others, venesection, opium, or diaphoretics are found most beneficial. 6th. In commencing with any plan of treatment in this disease, it is proper to ascertain the quantity of solids and liquids daily taken, in order to be enabled to institute a com- parison with the urine and its contents after- wards. A chemical examination of that secretion ought never to be omitted before the trial of any remedial measures, and during the progress of the complaint; as it enables the practitioner to deter- mine with accuracy one most important point, namely, the quantity of saccharine matter it con- tains, and to ascertain the gradual advances to- wards recovery. The urine may assume nearly a natural colour, and lose all its diabetic proper- ties to the taste and smell, when, on being eva- porated, its residuum is found to afford a saccha- rine impregnation, showing that the disease is not completely subdued. From inattention to the evaporation and analysis of this fluid, medical men occasionally overlook the real nature of the disease. The specific gravity of the urine ought also to be very carefully ascertained, for it is im- possible to pronounce with any degree of accuracy respecting the removal of this disease, or the bene- ficial change produced by any curative method upon the urinary secretion, without making occa- sional examination of the specific gravity of that discharge. So long as the specific gravity of the urine remains beyond the natural standard, the cure cannot be considered perfect, although the patient may be capable of resuming the ordinary duties of life. James L. Bardsley. DIAGNOSIS. This term is derived from it* and yivwo-KO), to know, and signifies distinction in 626 DIAPHORETICS. general; in medicine it is employed to designate the distinction of diseases. It is necessary, before giving a detailed view of the diagnostic arrangement of diseases, to enter upon the general consideration of symptoms, as the principal source on which the distinction of diseases depends; and as symptomatology, or the doctrine of symptoms, cannot properly be con- sidered under diagnosis, we propose to treat of the symptoms and diagnosis of diseases under the term Symptomatology. Marshall Hall. DIAPHORETICS, (hiaQopvriKa fdppaxa, from 6iaiou>, fero, porto,) are medicines that augment the function of perspiration. In order to understand the mode in which they operate, we ought to possess an accurate idea of the manner in which the cuticular function is performed in a state of health. The importance of perspiration for the pre- servation of health is well understood, but the laws to which it is subjected are still imperfectly determined. It is a function of the whole of the skin ; but whether it is possessed equally by every part of it, has not been ascertained ; it is, how- ever, probable that some parts perspire more freely than other parts. The perspiral matter passes off either in the form of a thin, invisible vapour, as insensible perspiration; or in a liquid form, as' sweat. Various attempts have been made to ascertain the quantity of the cuticular discharge. From the time of Sanctorius, who first endeavour- ed to determine it experimentally, to that of La- voisier and Seguin, little confidence could be placed on the results of the experiments, as the amount of the pulmonary exhalation was not de- ducted in calculating the loss which the body sustained in a given time. Lavoisier and Seguin overcame this difficulty, by inclosing the whole body in a silk bag, varnished with caoutchouc, having a small opening carefully cemented round the mouth, which permitted the person to breathe. The quantity of the cuticular discharge was thus determined to be one pound fourteen ounces in twenty-four hours; (Meinoires de l'Academie des Sciences, 1790, p. 610,) and, as this was the result of repeated trials, we may regard it as the average quantity in a state of health. Many circumstances tend to vary the loss by perspiration, not only in different individuals, but in the same person at different times, and under a diversity of circumstances ; as, for instance, the vigour of the frame, the nature and quantity of the ingesta, the temperature of the atmosphere, and many external relations. Thus perspiration is diminished immediately after a meal, but aug- mented during the process of digestion : it is also promoted during sleep; in a dry state of the at- mosphere ; in a current of air; and under a diminished barometrical pressure. But these cir- cumstances are supposed to promote perspiration independent of vitality ; and therefore Dr. Edwards has divided perspiration into that which results from ordinary physical influences, and that wliich is dependent on vitality or secretion ; or into ex- halation and secretion. Both are liable to be affected by external agents. In low tempera- I turcs, the loss by evaporation exceeds that by secretion, because cold suppresses secretion more than it impedes evaporation. It may, indeed, be maintained that even in a low temperature the \ cutaneous capillaries are still stimulated ; and, ! consequently, that the portion of the insensible ; perspiration, which is the result of vital energy, I must still be supplied : but it is in the ratio only of the stimulus which excites the vessels that furnish it: whilst the evaporation is less diminish- ed, because the air being heated by contact with the body, is enabled to hold more moisture in so- lution than the air farther removed from the body ; and thence evaporation is favoured. One evident intention of perspiration is to pre- vent the temperature of the body from rising above that degree which a state of health requires, and to operate as a balance to the heating in- fluence of increased arterial action. It also coun- terbalances other secretions ; as for instance that of the kidneys, which is diminished as the per- spiration is increased, and augmented when it is checked — a physiological fact of much practical value. Many experiments have been made to ascertain the chemical nature of the perspired matter. From all that is known, it may be concluded that it consists chiefly of aqueous fluid, containing in solution some free lactic acid, lactate, muriate, and phosphate of soda, and an oleaginous princi- ple : but there is also reason to believe that gase- ous fluids are perspired by the skin with bases of nitrogen,* carbon,-|- and hydrogen ;t and to the presence of the latter, variously modified by the accession of other constituents, some physiologists attribute the odour of perspiration. This odour, however, seems rather to depend on the secretions of the mucous follicles mingling with the perspi- ration, than to be a quality of this fluid, as it differs in different parts of the body. Contemplating the nature of the perspiratory function, we may conclude that it is intended to answer two purposes :—1. to convey caloric from the body, and thereby to moderate and regulate its temperature ; 2. to carry off a large quantity | of carbon and hydrogen from the circulating mass. Disease is frequently the consequence of a sud- den check to the perspiratory function; means, therefore, have been sought for to restore it; and substances which have the power of effecting this are termed diaphoretics. Let us now inquire in what manner they produce their effects. [The writer has elsewhere attempted to show (General Therapeutics and Materia Medica, i. 308 : Philad. 1843), that in any mode of viewing the subject, it does not appear that we can ascribe any extensive series of morbid phenomena to : simple obstruction of perspiration; and that, con- | sequently, the indication of restoring suppressed | perspiration, if it be admitted at all, must exist , much less frequently than has been imagined.] * Vide Tngenhouz's Experiments ; Experiences stir les ! Vegetaux, loin. i. p. 15a; and those of Tmusset, Annates de Chiinie, torn. xlv. p. 73. t Vide Experiments of Count de Milly : llistoire de l'Academie Koyale des Sciences et Belles Lttlres de Ber> liii. 1777, p. 35. X Experiments on Inspntible Perspiration, by W. rrtiickshanks; Jurine's Experiments, llistoire u> la So- eiete Royaie de .Medecine, torn x.; and those ut' Aber- nethy, detailed in his Surgical aud Physiological Essays, DIAPHORETICS. 627 Diaphoretics may operate in \wo ways:—1st, by stimulating generally, and so augmenting the force of circulation as to propel the blood forcibly through the minute vessels of the corium, by which both the secreting power of the skin, and the excretory function of the exhalente, is in- creased ; 2dly, by the absorption of the diaphore- tic substances taken into the stomach, and the direct application of these to the cutaneous capil- laries. In the healthy state of the system, perspiration is, probably, always the result of stimulating, either directly or indirectly, the cutaneous exha- lente ; and sweating follows increased vascular action, whether this arise from muscular exertion, or from substances taken into the stomach. But .in disease, when the temperature of the body is augmented, the pulse is often frequent, indicating increased excitement of the general circulation, yet the skin remains dry. In this state there is evidently diminished action of the exhalents, whilst the cutaneous capillaries have their secreting power impeded; and, therefore, this condition must be overcome before diaphoresis can be pro- duced. Those substances which augment the force of the general circulation, whilst at the same time they excite the cutaneous exhalents, will effect this desired change ; few substances produce this double effect, alone, but it is readily induced by some combinations. Those diaphoretics which operate by augment- ing the force of the vascular system, increase the frequency and the power of the pulse, and raise the temperature of the body, previous to the flow of perspiration : on the other hand, those which act by stimulating the cutaneous exhalents without augmenting the force of the general circulation, exert a primary influence on the nervous energy of the stomach, and the skin responds by that in- explicable connection to which the term sympathy has been applied. As the primary effect of diaphoretics is the evacuation of a large portion of the aqueous part of the blood, it might be supposed that this vital fluid would in consequence become thicker; but various circumstances concur to prevent such a result. Amongst others, thirst always accompa- nies sweating; and as this forces us to take fluids into the stomach, the waste of the aqueous matter thrown off by the skin is rapidly supplied. At this time, also, other fluid secretions are dimin- ished, the urine, for instance; so that the watery matters which would be carried off by them are diverted to the surface, and several substances, which naturally find other outlets, are expelled by the skin. This is clearly demonstrated in some diseases. Thus, in cases of ischuria renalis, the perspiration has been found to contain uric acid and other traces of urine. Dr. Percival relates a case in which the perspired matter was so satu- rated with the salts of the refluent urine, as to crystallize on the surface of the body, in the form of a white powder. Such a condition of circum- stances is, indeed, not surprising, when we con- sider that the suppression of one secretion induces an unusual action in the vessels of some other organ, and a changed condition of the secretion. One unquestionably beneficial effect of diapho- retics is the determination of the blood from the interior to the surface, thereby relieving conges- tions, and maintaining that due balance of the cir- culation which appears to be essential to the pre- servation of health. Their salutary influence is also displayed in the increased power which they bestow on the absorbents, and in their relaxation of the surface in febrile affections. The relaxing effect of diaphoretics is indeed the most important property they possess as remedial agents, as it is on this power that their utility in inflammatory affections depends. Were it, however, attempted to induce diaphoresis in inflammatory or febrile affections by stimulating diaphoretics, the desired effect would not only be prevented from taking place, but the hazardous symptoms would be ag- gravated. Several circumstances, therefore, are requisite to be attended to, in the administration of this order of medicines : we shall mention those most important in a practical point of view. 1. Whenever diaphoretics are indicated, the patient should be confined to bed, but not over- loaded with bed-clothes. If the pulse be full, hard, and quick, and the skin hot, bloodletting, if not contra-indicated by some peculiar circumstance, should preface the use of the diaphoretics; and the bowels should also be freely opened. It is a correct opinion, that free perspiration is not con- sonant with a quick, hard pulse, and a tempera- ture of the skin exceeding 102° of Fahrenheit: in this state, if sweating occur, it is generally par- tial, and rather injurious than salutary. Even after the reduction of the phlogistic diathesis, the diaphoretics to be selected are those which nau- seate and relax the surface. 2. The free use of diluents is necessary during the operation of diaphoretics, unless the stomach be in a highly irritable state. If antimonial dia- phoretics, however, be employed, acidulated fluids should not be taken soon after the dose of the antimonial, as vomiting would be induced. When the temperature of the surface is high, the dilu- ents should be cold ; but when it is moderate, they should be tepid. So important, indeed, is dilution in promoting the action of diaphoretics, that the mere introduction of cold or tepid fluids into the stomach during the hot stage of fever, often produces diaphoresis. 3. During the operation of diaphoretics, it is essential to use bad conductors of caloric as cover- ings : both the body-clothes and the bed-clothes of the patieht should be flannel, which, being of a light spongy texture, not only preserves an uni- form temperature, but also absorbs the moisture as the perspiration flows. When linen is em- ployed, the moisture accumulates in it, and aiding its conducting power, carries off the heat too ra- pidly from the body, and chills the surface. At- tention to this circumstance is most essential, if it be requisite to keep up the sweating for ten or twelve hours longer, and especially if sleep be- come necessary during the continuance of the sweating. The older practitioners invariably re- sorted to the use of flannel during diaphoresis; a custom which has been too hastily condemned by modern practitioners, who recommend, instead of flannel, frequent changes of well-aired linen, as- serting that this is more refreshing to the patient, that, from its comfortable feel, it has a tendency to allay irritation, consequently to aid in subdu- 628 DIAPHORETICS. ing the restlessness and inquietude of fever; and that it is essential for carrying off the fomes of the disease. The last part only of this opinion is well founded; and few practitioners would place a patient labouring under an infectious fever in flannel: indeed, under such circumstances, perspiration to the extent which requires the use of flannel is neither necessary nor desirable. 4. Attention must be paid to the state of the bowels and kidneys. If perspiration be requisite in a low stage of fever, purging must be studiously avoided, and should be checked if it occur spon- taneously whilst the sweat is flowing; as it is al- most certain to stop the sweating and to aggravate the disease, by diverting the blood to the interior, and exposing the patient to cold. The utmost caution, indeed, is requisite to prevent the admis- sion of cold air to the surface ; and no cold li- quids should be taken into the stomach whilst the sweat is flowing, and for some time after it has eeased. During the administration of diaphoret- ics, every thing which has a tendency to promote the secretion of the kidneys should be avoided. The avoiding a frequent change of linen is in conformity with this rule, as, in affecting these changes, the surface must be necessarily exposed. 5. The morning, directly after sleep, is the best period of the day for administering diaphoretics, as the system is then easily excited, and the sur- face is relaxed : experience has demonstrated that many persons in whom perspiration cannot be induced at any other period of the day, may be readily made to sweat at that time. When per- spiration accompanies diseases, it generally hap- pens in the morning ; there is then, also, a natu- ral decline of febrile excitement; thence it is the most favourable time for the action of diaphoret- ics : and besides, as the administration of diluents is necessary to maintain the diaphoresis, this is the more convenient period for their administra- tion. 6. When sweating is to be checked, the skin should be dried with soft warm towels; the pa- tient should be carefully moved into dry flannels, and the coverings gradually lessened, allowing the arms to be cautiously exposed to the air. By these means, the injurious consequences, which might follow a sudden revulsion, are avoided. Before entering upon the examination of those substances and means which are usually employ- ed to promote diaphoresis, it may be proper to state why we arrange them under the two follow- ing heads :— 1. Diaphoretics, which cause a copious watery, cutaneous excretion, or flow of svjeat. 2. Diaphoretics, which only augment the ordi- nary perspiration. The first set excite the cutaneous capillaries and exhalents to a degree sufficient to increase both the secretory and the excretory functions of the skin beyond that point at which the perspired matter is carried off in the insensible form; thence it appears as sweat, and the substances inducing it ought to be distinguished from other diaphoretics. They are properly termed sudorifics. The second set operate in the same manner, but so moderately that they merely augment the ordi- nary insensible perspiration. It is true that both these results may be obtained by modifying the dose of the substances employed, and the circum- stances under which they are administered; but nevertheless there are substances which, all cir- cumstances being equal, produce a more powerful diaphoretic effect than others ; and, therefore, this division is useful. 1. Sweating may be produced in two ways : by substances taken into the stomach ; and by applications to the surface. a. The substances capable of producing sweat- ing when taken into the stomach — sudorifics— belong both to the organic and the inorganic kingdom of nature. Among the first, ipecacu- anha, the root of the cephaelis ipecacuanha, which has been long known as a valuable sudo- rific, owes its properties to a peculiar alkaline principle, discovered by M. Pelletier, in 1817, named emetia* Separate from the ipecacuanha, emetia has not yet been introduced into general practice in Great Britain, although it is much employed on the continent. Ipecacuanha in moderate doses, one grain or less, is well calcu- lated to produce sudorific effects; but it is seldom administered alone for this purpose, being gene- rally combined with opium, the narcotic influence of which it moderates, whilst its own diaphoretic powers are augmented by the combination. It exists in this state in the compound powder of ipecacuanha of the British Pharmacopoeia}, ten grains of which, a full dose for an adult, contain one grain of ipecacuanha and the same quantity of opium. In prescribing this powder, or ipeca- cuanha itself, or its infusion in wine, although it may be advantageously combined with camphor or with nitrate of potassa, yet it ought not to be prescribed in conjunction with astringent decoc- tions or infusions, as the tannin unites with the emetia, forming an insoluble tannate, which is inert. Its sudorific effects, when once begun, should be maintained by copious dilution with tepid fluids; but tepid drink should never be taken immediately after the powder, otherwise it may be rejected by vomiting. It should, also, be recol- lected that the diluents should not be acidulated, as the combination of vegetable acid with emetia is more likely to run off by the bowels than to exert a diaphoretic influence ; at the same time, as it is advisable to add something to the tepid water to prevent the nausea extending to vomit- ing, lemon-peel may be infused in toast-water for that purpose. Mezereon, the inner bark of the roots of daphne mezereum, is also supposed to owe ite sudorific property to an alkaline principle, daphnina,^ which was first procured by Vauquelin from the daphne alpina,- but this is uncertain. Mezereon is a stimulant sudorific, exciting, powerfully, the * The emetia, in its separate state and pure, is white, pulverulent, and unalterable in the air, of a slightly flitter taste, inodorous, sparingly soluble in cold water, hut soluble in hot water and in alcohol and ether. It is seldom obtained in this state, but is usually of a reddish- brown colour and deliquescent. One hundred grains of good ipecacuanha contain sixteen of emetia. MM. Magendie and Pelletier suppose that ii is taken into the circulation, and exerts a specific effect on the lungs, and on the mucous membrane of the intestinal canal. t Daphnina, when pure, is a colourless, inodorous alkaline salt, which crystallizes in transparent brilliant crystals, soluble in water, alcohol, and ether. The alka- lies, lime water, and barytic water, tinge its solution of a golden hue; nitric acid, converts it into oxalic acid. DIAPHORETICS. 629 heart and whole arterial system: it is apt to cause vomiting and purging. It has been found very useful in chronic rheumatism, and, in conjunction with the liquor arsenicalis, in obstinate cases of lepra, and some other chronic cutaneous affections. It is probably to its sudorific property that we are to ascribe its beneficial influence as an ingredient in the compound decoction of sarsaparilla, in secondary syphilis and many chronic diseases. We are aware that Mr. John Pearson states, that he had " very seldom found it possessed of medi- cinal virtue, either in syphilis or in the sequelae of that disease, in scrofula or in cutaneous affec- tions."* Our experience prevents us from accord- ing with this opinion. Its sudorific powers may be secured by administering an infusion, made with two drachms of the bark in a quart of hot water, in doses of f.^ii. every four hours. Guaiacum, the concrete juice of the guaiacum officinale, was known as a diaphoretic so early as 1508, and was used by the natives of St. Domingo as a specific in syphilis; but although, when administered alone, it possesses no influence over lues venerea, yet it is a powerfully stimulant sudorific, and proves useful in impetigo and some other cutaneous eruptions; in ozoena, and in scro- fulous affections of the membranes and ligaments. Its utility in these cases may depend on its power of augmenting the energy of the absorbents and the cutaneous capillaries, thereby improving the state of the cuticular function. In chronic rheu- matism, a solution of guaiacum in aromatic spirit of ammonia, the tinctura guaiaci ammoniata, given in doses of from f.^ss. to f.^ii. at bed-time, and its sudorific powers aided in the morning by copious dilution with tepid fluids, has been productive of much benefit; and it is equally serviceable in atonic gout : but its boasted efficacy as a gout medicine has never been realised; and even in chronic rheumatism the remark of Dr. Ferriar, that although in some forms of the disease it proves serviceable, in others it produces no effect whatsoever, is no doubt correct Dr. Chapman makes the following remarks on the efficacy of guaiacum in a morbid affection of the eye : — " There is a morbid affection of the eye of gastric origin, hitherto not sufficiently noticed, where, although no external inflammation exists, or so slightly as hardly to be perceived, there is great intolerance of light; sometimes very acute lanci- nating pains through the ball, although more generally the sensation is that of a dull obtuse ache, attended with much heat and aridity of sur- face, which, whatever may be its nature, is very successfully treated by the guaiacum." (Chap- man's Materia Medica.) Dr. Chapman appeals to his own experience of the efficacy of this medi- cine, and affirms that he never saw the disease rured.by any other—[yet the affection appears to he unknown to every other pathologist and thera- peutist] Asa sudorific, guaiacum acts freely only when the surface is kept warm; otherwise, it excites the urinary discharge. The more minutely the guaiacum is divided, the more certain is its sudo- rific power; and, therefore, the tincture, decom- * Pearson's Observations on the Eli'.xts of various Articles of the Materia Medica, in the cure of Lues Venerea, Loud. lfcOO, p. 49. 3o posed by water, if the precipitated guaiacum be rubbed up with mucilage to suspend it in the liquid vehicle whatever it may be, is the best form in which it can be prescribed. The dose of either of the tinctures is from f/Jss. to f.Jiii. The am- moniated tincture is to be preferred in atonic gout. It is unnecessary to enter into any details re- specting those sudorifics which owe their powers to volatile oil. They are all too stimulant to be employed as sudorifics, except in diseases of dimi- nished energy. In the low and sinking stage of typhus, serpentaria often proves beneficial; when, although the dry hot skin indicates the necessity of a sudorific, yet the nauseating and relaxing diaphoretics would prove injurious. It has also been found useful in dyspeptic affections accom- panied with a dry skin, and is an excellent adjunct to cinchona or its salts in protracted cases of in- termittents, and in atonic gout. The only inorganic substances of value as sudorifics are the preparations of antimony. All of them may be so managed as to produce sudorific effects, but the most manageable and certain is the tartrate of antimony and potassa ; and, in small doses, of from one-sixth to one-fourth of a grain, it seldom fails to procure copious sweating. The experiments of Dr. Elliotson have completely demonstrated the inert character of the pulvis an- timonialis of the London Pharmacopoeia; and the writer of this article has satisfied himself, by an experimental investigation, that it bears no resem- blance to the true James's powder, the place of which it is intended to supply. The antimony in James's powder is in the state of a soluble pro- toxide ; in the pulvis antimonialis it is usuallyf in that of an insoluble peroxide; and as it is un- doubted that the more soluble the salts of antimony are, the more certain and powerful is their sudorific influence, it is easy to explain the general ineffi- cacy of the antimonial powder, 130 grains of which have been given, three times a day, without producing even nausea. (London Medical Ga- zette, December 1831, p. 463.) But, at the same time, it must be admitted that no medicines are so much modified in their effects by idiosyncrasy as antimonials: in one person, small doses of tartar emetic will induce only moderate sweating; in another, the same dose will cause alarming vomiting and purging, extreme depression of bodily strength, and excite a degree of nausea which cannot be allayed. The influence of antimonials is much augment- ed by combination with other substances, as cam- phor, calomel, and opium ; but, in prescribing tartar emetic, it should be recollected that it is decomposed by alkaline carbonates, by the medi- cinal soluble salts of zinc, lead, bismuth, and mercury ; and that an insoluble tannate is formed with the protoxide of antimony, when tartar emetic is added to any of the astringent vegetable infu- sions or decoctions, with the exception of those of oak-bark. The tannate thus formed is inert; on which account decoction of yellow cinchona t We say usually, because no preparation used as a remedial agent is so variable in its nature. In a few specimens we have found a small proportion of the pro- toxide: but in far the greater number of the specimens examined, the antimonial is in the state of a peroxide. 630 DIAPHORETICS. is the antidote of tartar emetic. In acute rheuma- tism and other inflammatory affections, a combi- nation of one grain of calomel, one-fourth of a grain of tartar emetic, and from one to two grains of opium, administered every fourth or fifth hour, produces everything that can be expected from a sudorific: indeed, when the intention is to deter- mine powerfully to the surface, the tartrate of antimony and potassa, in small doses, repeated at proper intervals, and aided by warmth and diluents, is, as we have already said, more ma- nageable and certain in its effects than any other of this order of remedial agents. 6. Those agents which, applied to the surface, produce sweating by directly stimulating the cuta- neous capillaries, are warm and hot baths, vapour- baths, hot air-baths, and the cold affusion. For the modus operandi, and manner of administering these, we must refer to the article Bathing. 2. The diaphoretics which merely augment the ordinary perspiration produce their effect in three ways:—1. through the medium of the stomach ; 2. by entering the circulation, and acting directly on the skin ; 3. by application to the surface. Among the substances of this division of dia- phoretics which operate through the medium of the stomach, we think it unnecessary to say any- thing either of musk or of castor. With respect to dulcamara, (the twigs of the solanum dulca- mara,) which owes its efficacy to a peculiar alka- loid, named solania, either diaphoresis or diuresis may be produced by it, according to the extent of the dose or the manner in which the surface of the body is managed during its administration. It generally produces nausea, and not improbably much of its diaphoretic influence depends on this circumstance ; and on this account the dose should be gradually increased during its administration. Two fluidounces of the decoction, made with ^i. of the bruised twigs boiled in a pint and a half of water down to a pint, given three times a day, seldom fail to induce and maintain a gentle breathing perspiration. Camphor certainly pro- duces a tendency to diaphoresis, without increasing the velocity of the pulse; and, therefore, it forms a useful adjunct to more decided diaphoretics ; but with respect to sarsaparilla, even this is doubt- ful ; and We are disposed to think that the diapho- resis which it is supposed to produce is due to the tepid diluent regimen which is generally prescribed during a course of it. Among the inorganic substances belonging to this division of diaphoretics, we find the carbonate and citrate of ammonia, citrate of potassa, and acetate of ammonia. The first stimulates the nervous energy, and produces diaphoresis when aided by external warmth and plentiful tepid dilu- tion ; it is indicated in the sinking stage of typhoid fevers, and other debilitated conditions in which diaphoresis is still desired ; but otherwise its place can be much better supplied by many other sub- stances. In combination with guaiacum and opium, considerable advantage has been obtained from it in obstinate cases of chronic rheumatism. To produce its diaphoretic effect the dose should not be less than twelve grains, nor more than twenty: the best vehicle for administering it is the almond emulsion. The citrate of ammonia, which is generally prepared at the moment of its administration by saturating recent lemon-juice with carbonate of ammonia, possesses very mode- rate diaphoretic powers; but it is less nauseous than the acetate, and forms an excellent vehicle for tincture of opium, when it is desirable to pro- mote its diaphoretic influence. The same remarks apply to the citrate of potassa, which is more fre- quently employed than the former preparation, especially when the stomach is in a highly irrita- ble state. The old method of administering the saline draught—first swallowing the solution of the alkali, and immediately afterwards the lemon- juice, although now seldom recommended, yet had its advantages. The alkaline solution allays the irritability of the stomach, whilst the close ap- plication of the carbonic acid, extricated in the stomach, to the nerves of that viscus, affords a certain degree of tone without interfering with the diaphoretic operation of the neutral salt formed by the union of the two bases. The best of the neutral salts, however, for inducing diaphoresis is the acetate of ammonia in solution, the old spiri- tus Mindereri. The common solution of this salt, the liquor ammoniae acetatis, is generally very carelessly prepared, and little pains taken to pro- duce a strictly neutral solution: when the alkali predominates, the solution of tartar emetic, occa- sionally prescribed with it, is decomposed ; when the vinegar is in excess, the usual dose of the an- timonial excites vomiting. The crystallized salt formed by saturating strong acetic acid with am- monia, being always neutral, should be employed in solution in preference to the usual preparation. When perfectly neutral, the solution is an excel- lent vehicle for soluble antimonials and opium, aiding considerably the effect of both on the skin ; it is also easily retained on the stomach, and fre- quently allays the irritability of that organ when administered in doses of f.^iii. to f.^xii. in any bland fluid. The last of the substances necessary to be no- ticed in this section of the second division of dia- phoretics is water. The greater part of the fluid perspired by the skin is water; and if the surface be kept warm, so as to check the action of the kidneys, the proportion is generally in the ratio of the quantity of fluid taken into the stomach. But besides this cause of the diaphoretic influence of water, it is also well known that the sudden impression of a draught of cold water upon the nerves of the stomach acts most forcibly in pro- moting diaphoresis. A person who awakes in the night with the tongue feverish and parched, a quick pulse, and a dry, hot skin, finds immediate relief from swallowing a large draught of cold water: the cutaneous capillaries immediately con- sent with the stomach, and copious perspiration often ensues. By imitating this practice in fevers a similar result is occasionally obtained. When water is to be employed as a diaphoretic, much depends on the management of the patient during its administration. If the surface be kept warm, and the body surrounded with bad conductors of caloric, a moderate quantity of water will produce the effect required. Under these circumstances, cold water is to be preferred to warm ; but it must be kept in remembrance that in delicate constitu- tions, even in fever when the excitement is high, a sudden reduction of temperature is hazardous, DIAPHORETICS.—DIARRHCE A. 631 and, therefore, tepid drinks are necessary ; and small quantities of aromatics may be added to the aqueous fluid to moderate the nausea which tepid water always produces. Besides being diaphoretic itself, water is the general auxiliary of all other diaphoretics; nor can the influence of the best of them be main- tained without ample dilution. In this case the fluid employed should always be tepid, at least of a temperature not under 65° Fahrenheit The same rule, indeed, is necessary for the administra- tion of diluents as for the external employment of water; when the temperature of the body is under 96°, cold drink should not be ordered. Nature points out the best indications for using water, both as to its administration at first and its continued employment, by the sensation of thirst which accompanies every state of febrile action : when this is present, we cannot err in prescribing water, the temperature being determined by that of the body and the state of the skin. Among those substances which enter the circu- lation and operate as diaphoretics by their direct influence on the skin, the first, which we have to notice is sulphur. When this substance is taken into the stomach, it passes off through the cuta- neous exhalents united with hydrogen; a fact demonstrated by silver, worn in the pockets of those taking it, assuming the same dark hue as if it had been exposed to a stream of sulphuretted hydrogen gas; and as it thus passes off, it excites diaphoresis. As a diophoretic, sulphur is em- ployed in cases of chronic rheumatism and some other skin diseases; and in combination with oil, the oleum sulphuratum of the London Pharma- copoeia, in chronic catarrh: but this is an acrid, nauseous preparation, and consequently seldom administered. In combination with potassium, sulphur forms a solid preparation, hepar sulphuris, which by solution in water is converted into a hydro-sulphuret of potassa. Both of these pre- parations have been employed as diaphoretics in chronic affections of the chest, and in several cu- taneous diseases. The action of the salts of mercury upon the capillary system has been long known ; and in having the cuticular discharge promoted by them, it is probable that the skin only shares, as a secret- ing organ, in the general influence which they exert on the glandular system ; but although their influence on the cutaneous function is demon- strated by daily experience, yet they are only employed as auxiliaries in promoting diaphoresis. Calomel, the prolochloride of mercury, is the pre- paration usually selected for obtaining the effect of mercury on the cuticular exhalents; and it is generally conjoined with tartar emetic or James's powder, ipecacuanha, guaiacum, or opium; to which it imparts additional sudorific power. In these "combinations, calomel is given with ad- vantage in all inflammatory diseases ; and, in the form of Plummer's pill, in cutaneous eruptions and in chronic rheumatism. In this pill the an- timonial is the antimonii sulphuretum pracipita- tum of the London College, a preparation pos- sessing more certain sudorific properties than the pulvis antimonialis : whether an influence can be ascribed to the guaiacum, considering its small proportion to the more active ingredients in this pill, seems doubtful. As a diaphoretic, the dose of calomel should not exceed one grain, frequently repeated. c. Whether sweating or mere diaphoresis be produced, the cause of both, as far as they are the result of the substances to which we have already referred, is the augmented action of the whole vascular system ; but diaphoresis may be pro- cured by the excitement merely of the cutaneous capillaries. The natural insensible perspiration is, indeed, apparently the effect solely of the cuticular system of vessels ; and although means exist by which this may be carried to sweating, yet still the cause is confined solely to the cuticular ves- sels. Friction operates in this way, acting on the surface, in a manner equivalent to muscular exertion on the whole habit, in augmenting dia- phoresis. The tepid bath produces its effects on the same principle, although both the degree and the nature of the stimulus be different. When the tepid bath is employed, it is necessary to con- tinue the application for a considerable time to produce the desired effect. The first result of ite application is emollient, the second diaphoretic. In remarking on the practical employment of diaphoretics, we should say that they must be selected according to the nature of the disease, and the object to be accomplished. Those that operate by augmenting the force of the general circulation are well adapted for relieving internal congestions ; those which produce nausea and unload the oppressed capillaries, are adapted for diminishing febrile action, and reducing the mor- bid temperature of the body. With respect to the diseases in which diapho- retics are beneficial, we must refer to the various articles which are devoted to their consideration. [It may, however, be doubted whether we have any internal remedies that are capable of acting as direct diaphoretics,—that is, by virtue of spe- cific properties which they possess over the glan- dular or diapnogenous apparatus of the skin. In every case in which the skin is hot and dry, and the indication appears to be to establish diapho- resis, the cause of this condition of the cutaneous exhalents must be inquired into, and if possible removed. Hence it is, that the well-instructed practitioner employs indirect diaphoretics rather than such as are esteemed direct. Thus, dimin- ished sensible exhalation takes place from the skin during the existence of fever or inflamma- tion, but the physician does not have recourse to any reputed diaphoretic, which acts by exciting the sanguiferous system. He adapts his antiphlo- gistic remedies so as to reduce the already too much excited condition of the blood-vessels, to the healthy standard; and he finds, when he has re- moved the internal inflammation, the heat and dryness of the skin subside, and diaphoresis satis- factorily established. Under similar circumstances, a full dose of opium is attended with a similar re- sult. Opium in a full dose is a sedative ; and hence morphia, in large doses, is often so power- fully diaphoretic. Nauseants are most effective diaphoretics in diseases of excitement; and they are powerful sedatives. On the whole, even in febrile and inflammatory affections, the use of the ordinary internal diaphoretics is uncertain, and generally of no avail; and many of them are de- 632 DIARRHOJA. cidedly injurious by their excitant properties; yet, in many such cases, advantage may be derived from the equalizing influence of the warm-bath ; and in minor inflammations, especially of the gastro-pulmonary mucous membrane,—as catarrh, —warm diluents, aided by the warmth and qui- etude of bed, produce an equalizing effect, which is often most salutary. In almost all cases in which the employment of diaphoretics appears to be indicated, the class of sedatives, (q. v.) or refrigerants, (q.v.) or both, will be found infinitely more advantageous. (Ge- neral Therapeutics, &c, i. 312.)] A. T. Thomson. DIARRHC3A, (Ato^oia, from Stapftiia, perfiuo, primarily from Sia, per, and j>f<*, fiuo) ; looseness, flux, lax. This is a very common and well-known disease, characterised by frequent'and imperative calls to go to stool, the evacuations being more liquid than the usual healthy discharges from the bowels. Pain or griping is occasionally an at- tendant, but not necessarily so. This disorder is frequently a matter of trifling importance ; at other times it is productive of serious consequences. Causes* — Diarrhoea may originate in very various causes. One of the most common is the direct application of stimulants to the interior of the digestive tube. Errors in diet, either in quan- tity or quality, will often act in this way. W'hen a great mixture of different kinds of food and drink is taken at the same meal, a sudden attack of diarrhoea is no uncommon occurrence, and need not be matter of surprise. In some constitu- tions a draught of cold water, beer, milk, &c. im- mediately affects the bowels, especially if the individual is heated at the time; and ices are often productive of the same effect. Unwhole- some articles of diet operate in a similar manner on many individuals. Of this kind are, animal food approaching to a putrid state, raw vegetables, cucumbers, melons, mushrooms, certain salads, &c* Diarrhoea is also a very common occur- rence in infants when the nurse's milk disagrees, or when other food is given too stimulant for their digestive powers, or in too great quantity. Diarrhoea occurs as a sympathetic disorder in many diseases, as in the dentition of children; and there are many affections of a more general kind where it is a frequent attendant. Measles, scarlatina, and other exanthemata, afford examples of this. In such cases there is little doubt that an excited or hyperemic state of the mucous mem- brane takes place : some have even supposed that an eruption analogous to that on the surface may l>e present. In gastric and enteric fevers, also, diarrhoea is a frequent symptom. It is often the initiatory state in cholera and dysentery ; and in some diseases, as fevers, it occasionally shows itself as a critical discharge. The diarrhoea which attends the latter stages of phthisis, and other * We have the personal testimony of no less a man than Cicero, that the substances last mentioned are pro- ductive of this complaint.— Dum volunt isti lauti terra nata, qux lege excepts sunt, in honorem adducere, fun- gus, helvellas, herbas omnes ita condiunt, ut nihil possit esse suavius. In eas quum incidissem in csna augurali apud Lentulum, tanta me Sidfyoia arripuit, ut hodie primum videar consistere. Ita ego, qui me ostreis et raurenis facile abstinebam, a beta etiam et a malva de- eeptus sum.—Epist. Fam. lib. vii. 1S7. forms of hectic and atrophic affections, is uni- versally known. Many causes give rise to diarrhoea in a less direct manner, such as exposure to cold, cold and wet feet, an atmosphere simply cold and damp, or impregnated with putrid exhalations, &c. With some persons exposure to warm and damp air is productive of the same consequences ; and alter- nations of temperature are often equally effective, as in the case of a hot day being succeeded by a chilly evening. Suppressed evacuations, as inter- rupted sweat, checked menstruation, the disap- pearance of abscesses, retrocession of the eruption of smallpox, measles, or scarlatina, are occasion- ally succeeded by diarrhoea. Many persons of a nervous temperament are subject to similar attacks on the least agitation of mind, anxiety, or sur- prise ; and when such mental states are present, the slightest errors of diet will be followed by liquid discharges from the bowels, although the same persons are exempt from any such attacks when no such disturbing causes are in operation, even when they indulge in a great variety of food. Morbid secretions from the liver and other glands that open into the intestinal canal, as well as irri- tating secretions from the mucous membrane itself, are also causes of diarrhoea. So likewise are worms generated there ; but less frequently than might be expected. Gout in many instances appears to maintain a tendency to loose discharges from the bowels, and to expend itself by this outlet. We have known several cases of persons who were accustomed to have three or four loose motions daily while in health; and when the least interruption to this ordinary habit took place, a.fit of regular gout came on, the diarrhoea re-appearing when the gouty attack had subsided. One gentleman had his first attack of gout on giving a check to a loose state of the bowels which he considered trouble- some; and for many years afterwards diarrhoea and gout constantly alternated. This is the diarrhoea arthritica of Sauvages, and is noticed by many practical writers, as Sydenham, Baglivi, Musgrave, &c. Many persons are liable to diar- rhoea on visiting certain cities, as London, Paris, Cork, Limerick, Galway, &c. The waters of such places are commonly accused as producing the complaint, but there are probably other causes. Diarrhoea often prevails epidemically without our being able to trace the precise cause; but in such cases it is commonly accompanied by catarrhal affections of other mucous membranes. Symptoms and different forms of Diar- hoea.—An attack of diarrhoea is, in most instan- ces, from whatever cause it may proceed, preceded by feelings of indigestion, nausea, flatulence, &c. It is usually attended by more or less pain or un- easiness in different parts of the abdomen, more especially before the bowels are called upon to act. In the more severe forms, the abdomen is often swelled, hot, and painful to the touch, and the discharges are announced by searching pains of various degrees, sometimes slight, sometimes very severe, and attended occasionally by fainting, and frequently by nausea, or even vomiting. The pain seems to follow the transit of the alimentary mass, and to be connected with the peristaltic con- tractions of the muscular coat of the intestines. DIARRHCEA. 633 The discharges take place without effort, and in some instances are involuntary. The patient feels weaker after each evacuation, yet experiences some relief from the pain, tension, and flatulent working in the bowels. The number of stools is very uncertain ; they may amount to ten, fifteen, twenty, or even twice that number, in the twenty-four hours. In the commencement of the attack they are abundant in quantity ; afterwards they become more scanty, and, whatever may have been their original con- dition, consist chiefly of a serous fluid mixed with fibrous threads. The discharges are more fetid in proportion to the quantity of proper excrementi- tious matter contained in thein. Paleness and wasting of the body accompany the severer at- tacks ; likewise a sense of chilliness, dry skin, a loaded tongue, and a diminution of the urinarv secretion. The patient becomes often so enfeebled as to he forced to keep his room or even his bed. The nature of the evacuations in diarrhoea has of course attracted the. attention of physicians in a very particular manner, and in most cases they have been considered as constituting the very es- sence of the disease. The discharges vary ex- tremely in colour, consistence, and other physical characters; and although this variety is often ob- servable in individual cases, either at one and the same instant, or at different periods of the attack, still, gcneially speaking, different cases commonly preserve throughout their.course one predominant ■character of the evacuations. On this fact has been founded the most common classification of diarrhoea which we possess, and which, variously modified, has obtained from the earliest times up to the present period. This classification is, no doubt, as we have just observed, founded in na- ture ; still it must be strongly impressed on the mind of the student and young practitioner, that the nature of the stools alone cannot be admitted as affording a true indication of the pathological condition of the parts which constitute the seat of the disease, and much less as a guide in practice. Constant attention to their character, however, can never be dispensed with on the part of the practitioner. For a full account of all the appearances of the discharges which have been considered as cha- racterising different species or varieties of diar- rhoea, we must refer to nosologists and systematic writers. We can only notice a few of the most remarkable. Feculent diarrhoea. — The evacuations in this variety are of the ordinary faecal character, but more liquid and more frequent than natural. This may be said to be present in the commencement of all the other forms, inasmuch as the faecal con- tents of the bowels must he evacuated either before the morbid secretions take place, or in conjunc- tion with them. What, however, has been usually termed feculent diarrhoea, is that in which the evacuations retain this character through the greater part of their course. This is the D. sler- corea of Sauvages, the D. crapulosa of Cullen, and the D. fusa of Good. It is apt to occur to those who have large appetites, and who have overloaded the stomach with a variety of food. It often comes on without warning and without pain. It is sometimes attended with dyspeptic symp- Voi. I___80 toms, but sometimes not It generally ceases of its own accord ; and though it leaves the patient somewhat debilitated, the healthy functions of the bowels are soon restored, provided the patient or his attendants are not too anxious prematurely to arrest the discharges, or again to overload the ! stomach with improper food. | Bilious diarrhoea.—This is not a very uncom- , mon form of bowel disorder, yet we believe it is often said to be present when the affection is merely that last described. In the proper bilious I diarrhoea, the stools, at first faecal, are loaded with a morbid proportion of bile, and are, in conse- quence, of a bright yellow or greenish colour. It is supposed to arise from an excited condition of i the liver producing a superabundant secretion of ! bile, or bile of a morbid character, which acts on the mucous membrane of the bowels as a stimulant. This state of the liver is frequently produced, we believe, by a primary affection of the duodenum, of an inflammatory kind, which either simply excites the gland to increased action, by what has been termed continuous sympathy, or produces in it a like condition with itself. In either case the result is an augmented flow, and probably a de- praved state of the bile. This species of diarrhoea : is often met with in those who live intemperately, I or whose hepatic organs have suffered in warm I climates. Intense moral emotions, such as a vio- lent fit of anger in sanguine temperaments, or grief and disappointment in melancholies, have been observed to give rise suddenly to it. The connection between the manifestation of the pas- sions of the mind and the secretion of bile, so familiar to our classical readers in the writings of the ancient physicians as well as poets, is founded in accurate observation, and rio doubt originated in the supervention of the form of diarrhoea now under consideration, to strong mental emotions. All our nosologists agree in terming this variety D. biliosa. Mucous diarrhoea.—In the true mucous diar- rhoea, the stools contain little or no proper ftecal matter, but consist chiefly of mucous or watery fluids, the former being predominant. The stools sometimes consist entirely of mucus, which is passed either in large continuous masses, or in separate flakes, intermixed with more liquid mat- ters; it is often found, particularly in the com- mencement of an acute attack, or rather, after thu has lasted a few days, quite transparent, and of the consistence of jelly; at other times it lies at the bottom of the pan like semi-transparent mu- cilage. The stools are of very various colours, depending chiefly on the degree of admixture with bile, but the characteristic features of the variety are to be sought for rather in the consist- ence and tenacity than in the colour. This form of diarrhoea is usually acute, and often reigns epidemically in conjunction with mucous fevers and catarrhal affections of the other mucous mem- branes, with some of wliich it occasionally alter- nates. It is often unaccompanied with fever, even when of considerable severity ; sometimes, how- ever, there is a very marked febrile state. It some- times assumes a more chronic or sluggish course in old delicate valetudinarians, who suffer from dyspeptic, hypochondriac, and other chronic ail- ments. In such cases, both the stomach and 634 DIARRHOEA. bowels are often loaded with depraved mucus se- creted in great quantity, and which appears to be the cause of the diarrhoea. In cases of this kind the mucous membrane is sometimes found thick- ened and congested, and the mucous follicles are erected and patulous ; and unless a suitable treat- ment is adopted, the disease degenerates into a permanently chronic state, probably with atrophy or dropsy. This is the D. mucosa of Cullen and Good, the Cxliaca mucosa of Sauvages. Serous diarrhoea.—In this form the discharges are quite serous or watery, and hence it has been termed diarrhoea aquosa by many authors. The stools may be coloured variously, or they may be nearly colourless; they may be almost limpid or intermixed> with minute flakes or shreds. Some- times they are intermixed with mucus, but their characteristic feature is their being copious and watery. In some cases the quantity of fluid pass- ed is very great, and speedily induces extreme debility. It is not always easy to distinguish this variety fiom cholera. Serous diarrhoea may be produced under the same circumstances as the mucous variety, and then it must be considered as an acute disease, and as being, in many cases at least, dependent on an excited or inflamed state of the mucous membrane of the bowels. At other times it would appear as if the serous discharge originated in an opposite condition of this part, the exhalents pour- ing out their contents rather from loss of tone, and passively, than by an active organic process. It sometimes succeeds profuse perspirations sud- denly repressed, or the imprudent use of acids and cold drinks when the body has been heated. It is sometimes the mode in which nature relieves herself from other diseases, as in dropsy, which has been known entirely to disappear on the su- pervention of a profuse diarrhoea of this kind. In very severe cases the discharges are so copious, and the emaciation and exhaustion so great, that it would appear as if almost the entire contents of the exhalent system were thrown upon the intestines. A marked form of this species is the diarrhoea of infants, termed watery gripes, in which the stools are often purely serous. This is the D. serosa of Sauvages and Good : it is in- cluded under the last variety (mucosa) by Dr. Cullen. There is a variety of diarrhoea termed tubularis by Dr. Good, and which may be more properly named flaky or membranaceous. It is more enti- tled to notice as throwing some light on the pa- thology of the disease than as a distinct species of diarrhoea. In this variety there is a discharge of coagulable lymph, generally in the form of shreds or bands of more or less extent, and some- times retaining the tubular shape of the bowel, whence Dr. Good derived his specific epithet. Such discharges are certainly met with in relaxed states of the bowels, but they are still more gene- rally, perhaps, observed in cases where constipa- tion is the habitual state. The fact is, that the peculiar inflammation of the mucous membrane, which gives rise to this morbid secretion, may pro- duce either constipation or diarrhoea; and it is probable that when the former state exists, the seat of the disease is in the small intestines, and when the latter, in the large intestines. We have frequently observed these fibrinous discharges in cases of temporary diarrhoea supervening to a long-continued state of constipation, whether ex- cited by improper diet purgative medicines, or occurring without any obvious cause. Such cases are, in fact examples of chronic enteritis, and not of diarrhoea. The chylous or milky diarrhoea of authors, and that termed gypseous or chalky by Dr. Good, are both denominated from false notions of their na- ture. We believe that the whiteness in the one case is no more owing to the presence of chyle, than in the other it is produced by lime, as Dr. Good supposed. The chief cause of the white colour in both these varieties is, no doubt, the absence of bile of the natural character or quan- tity ; but as this may occur in very different states, and when the discharges are in other respects very different, there is no sufficient reason for establish- ing any distinct form of disease on these grounds. It is proper to observe, however, that in chronic cases when the stools are of this colour, and more particularly if they resemble an admixture of chalk and water, as described by Dr. Baillie (Med. Trans. vol. v.), they for the most part indicate a disease of a serious, often of a dangerous character. The variety termed lientery, in which undi- gested aliment appears in the stools, has no claim to be considered as a distinct form of diarrhoea, as the circumstance supposed to characterise it may occur in every species pf the complaint. Nature of the Disease*—The foregoing ac- count of the principal phenomena and more mark- ed varieties of diarrhoea has necessarily anticipated much that might be said under this head. We shall therefore content ourselves with a few addi- tional observations. «»It is with difficulty," says Dr. Cullen, " that I have arranged this genus, as it is not very consistent with our plan to let it stand in our nosology. Diarrhoea is universally symptomatic of a great variety of diseases, many of which are different from one another; so that a genus formed from all these is a very complicated one, and comprehends many dissimilar affections and diseases." (First Lines, Dr. Thomson's edi- tion, vol. ii. p. 470.) This observation of Dr. Cullen is very just; but he might have gone even further, and stated that in a perfectly philosophical system of medicine, what is commonly termed diarrhoea would be regarded merely as a symptom of different pathological states, and would, there- fore, be banished from the list of individual dis- eases. We are, however, far from having attained to this perfection of pathology even in theory ,- and it is more than questionable if the adoption of such a view of the case in practice would ever be beneficial. The safer plan to follow is to con- sider the flux, termed diarrhoea, as a distinct dis- ease, but to regard it as the consequence of various morbid states in different cases ; the practitioner only taking care, before he applies his remedies, to ascertain the particular state which exists in the individual case before him, as far as his obser- vation and pathological knowledge enable him to do so. If he does not do this, but regards the flux only, without reference to its cause, he will be liable to commit grievous errors in his treatment. As a general rule, we may consider diarrhoea as having ite seat in the intestinal mucous mem- DIARRH03A. 639 / brane; and it is the state of this membrane, and not the discharge, which is to be regarded as the great object of attention to the pathologist and practitioner. The only exceptions to this rule are the cases where the disease is excited by fluids poured into the intestinal tube from the annexed glands, or by irritants of a temporary kind, as food or medicines, applied directly to the mem- brane. Even in these cases the secondary affection of the membrane is often of much more importance than the cause producing it. In the class of cases just mentioned, the mucous membrane of the bowels can scarcely be said to be diseased; and the functional disturbance speedily subsides on the removal of the offending cause. But in the great majority of the cases of diarrhoea the membrane is affected in a more permanent manner, although the degree of this varies ex- tremely. In the mildest form of the affection there seems to exist merely a morbid degree of irritability, or a morbid sensibility, in the mucous membrane, which scarcely exhibits any indication of disease, except when excited by something applied to it. What however, in a sound state would produce only the proper and natural degree of peristaltic action, now produces a morbid degree of action incompatible with perfect health. In another form of the affection there exists, perhaps in conjunc- tion with the foregoing state, a morbid degree of excitement or of increased action in the membrane, considered as a secreting and exhaling organ, whereby it throws out its fluids in a morbid state or in a morbid quantity, or both. In a third class of cases it is supposed by some that the exhalents, in place of being excited to increased action, are in a state of atonic relaxation, and thereby allow their fluids to escape in a condition no less de- viating from that of health. But in a still more numerous class of cases there exists a more permanent deviation from the healthy condition of the mucous membrane, namely, some form or degree of that pathological state to which we give the name of inflammation. In diarrhoea this state may exist in every degree, from the slightest shade of congestive irritation up to well-defined alteration of the normal struc- ture of the membrane: it may be confined to a small portion of the intestinal tube, or it may ex- tend over a large portion. In this form of diarrhoea, the evacuations deviate greatly from the character of health, and consist principally of fluids secreted by the inflamed membrane, being mucous or serous, or flaky from admixture of coagulable lymph, and very variously coloured according to the condition of the liver, the ingestion of food, the previous treatment, &c. In almost all cases the inflammation is confined to the large intes- tines ; but in some it extends to the small, and it may even originate there. The form of diarrhoea just noticed, and which may almost always be regarded as present in recent cases of much severity, and in which the stools are not faecal, can be considered as differing from the disease termed dysentery only in degree. When the inflammation is strongly marked, no doubt there supervene some peculiar symptoms— particularly the intermixture of blood with the mucous discharges, and fever—which do not exist in diarrhoea; but still the essence of both diseases is the same. Both are inflammations of the mu- cous membrane of the large intestines; but in the one the affection is slight, in the other it is severe. There is the same difference between them as there is between a mild pulmonary catarrh and bronchitis, but no more. The diarrhoea which almost always attends the latter stage of phthisis depends on ulceration of the mucous membrane. The ulcers in this case are often extremely numerous, being spread over the whole extent of the bowels, but they arc most common near the extremity of the ileum. Many other organic affections of the mucous membrane of the bowels, for the most part the consequence of inflammation, give rise to diarrhoea ; but cases of this kind do not come properly within the scope of the present article. The state of the mucous membrane found on dissection in simple diarrhoea, varies greatly in different cases. In recent examples, not connected with other diseases, opportunities for examination after death will rarely occur, as almost all such cases are cured. When opportunities of examina- tion have been found, the membrane, in recent cases, has been observed more or less red and con- gested, or extremely pale and anaemic, the redness being disposed in patches or in continuous stripes, leaving the intervening portions very pale. In cases of more severity and long standing, although still short of the degree constituting the dysentery of nosologists, a great variety of morbid appear- ances have been found. In these the membrane presents every variety of colour, from the most intense red, purple, or brown, to the blanched or anaemic state above mentioned, in which there is nothing to be seen in the vessels but colourless fluids. In other cases there is an enlarged and patulous condition of the mouths of the mucous follicles, which look erected, and sometimes in- flamed, and as if excoriated. The whole mucous membrane is also found thickened and oedematous, as in certain forms of dropsy, and is often greatly softened. The intestinal tube is frequently much contracted in its caliber. In some cases coagula- ble lymph is found adherent to the inflamed spots; but this is not of frequent occurrence: very tena- cious mucus of an inspissated character is com- mon. In many instances dissection detects scarcely any deviation from the state of health; and then we may reasonably suppose that the exhalents and mucous glands merely afford a rapidly in- creased supply. The termination of diarrhoea, when unattended by other, and especially visceral diseases, is for the most part favourable. But when the inflammatory state of the membrane becomes considerable, the disease then, under the name of dysentery, may lead to very serious results, ulceration taking place in the different tissues of the intestine, sometimes followed by perforation and fatal peritonitis. In some cases the inflammation of the mucous mem- brane extends or is transferred to the serous coat, giving rise to ascites. In this way diarrhoea and dropsy have been observed to alternate, according as the morbid action chiefly occupied the internal or external tunic of the bowel. When it assumes the chronic form, diarrhoea is sometimes a most obstinate disease, resisting in many cases, for 636 DIARRHCEA. months or years, every variety of treatment. When, however, it is not immediately dependent on great organic changes in the bowels or con- nected viscera, the general health is often much less affected, even in severe cases, than might be expected. We have known chronic diarrhoeas of considerable severity continue through the greater part of a long life. Treatment. — In undertaking the cure of a case of diarrhoea, it is often of as much conse- quence to consider its degree of severity and ite duration as its precise nature. Slight cases of every kind are in general easily removed; and in recent cases, even when severe, the mode of treat- ment is almost always simple, and generally suc- cessful. Acute or recent diarrhcea.— 1. in the common form of feculent diarrhoea recently produced by some known cause of irritation, as from improper food or otherwise, it is seldom that any other treatment is necessary except abstinence from food, with rest, and simple dilution. In such cases the offending matter is commonly itself speedily evacuated, and occasions at the same time a complete discharge of the whole fajcal con- tents of the bowels. When this is effected, the morbid action usually subsides of its own accord, and health is at once restored. Sometimes, how- ever, the offending matter is either not thrown off, or only partially, and a degree of excitement is kept up sufficient to irritate the bowels without unloading them ; the stools, partly faecal, partly mucous or serous, are scanty, and are accompanied with more or less of griping. The indication here evidently is to unload the bowels thoroughly; and it is best fulfilled by an active but not irri- tating purge, such as castor oil, rhubarb and mag- nesia, or the common senna draught of a moderate degree of strength. When the evacuations are free and complete, the irritation is commonly at an end. But sometimes, in place of being insuf- ficient, the evacuations are too copious; the irri- tating matter has acted like a drastic purge ; or the ineffectual efforts produced by the. primary cause have been raised beyond the healthy degree by the purgative, and the same result of hyperca- tharsis ensues. In cases of this kind the obvious and appropriate remedy is an opiate ; and few cases will resist the effect of this when combined with quiet, a warm bed, and abstinence. In feculent diarrhoea coining on without any very obvious exciting cause, in persons who are great eaters, or whose bowels are generally in a confined state, it will likewise be proper in most cases to administer a purgative, as the probability is that the cause of the diarrhcea is some irritating matter lodged in the bowels, and not any primary bource of irritation in the intestinal membranes ; and it may be stated, as a general rule, that in re- cent cases, if the motions are foecal, this practice will always be safe, and generally beneficial. Even in cases where the stools are altogether without proper faces,—mucous or serous,—if there exist any reason to expect an accumulation of feces in the bowels, a purgative will still be pro- per. The previous health of the patient, his ha- bits as to eating and alvine exoneration, the nature of the stools at the very commencement of the attack, and the degree of tension and hardness of the bowels, will, if duly weighed, in most cases lead to a just conclusion as to the point in ques- tion. Where there remains any doubt, the safest plan will be to give a moderate dose of a mild purgative, particularly castor oil, and be guided by its effects. If by its operation fsBcal stools are brought away, and the irritation still continues, a repetition of the dose or a still more active form of medicine will be proper. In persons whose bowels have been costive for some time before the attack, and also in those who are large feeders, and particularly if they lead sedentary lives, a dose of colocynth with calomel and antimonial powder may be proper, followed up after a few hours by the saline senna draught; the after treatment be- ing the same as before. 2. If the feculent diarrhoea is complicated or caused by a superabundant secretion of bile, it will be necessary to restore the liver as well as the bowels to its healthy functions. The unload- ing the bowels by purgatives may be at first ne- cessary ; but when this is effected, the treatment of the hepatic affection may be a work of some time. It is obvious that the consideration of this subject belongs rather to another place, (see He- patitis, and Liver, Diseases of) ; but we may be allowed to say a few words on it in reference to diarrhoea. If the augmented flow of bile or its depravation has been produced by a mere tempo- rary excitement little specific treatment will be requisite, as the disorder of function will in most cases be removed on the removal of the cause. What is more commonly called bilious diarrhoea is, however, in general, an affection of a more fixed character, depending, as we had occasion formerly to remark, either on an inflammatory state of the liver itself, or an excited condition of this gland transmitted through its ducts from an inflamed duodenum. In both cases the disease is usually of an acute character, and requires nearly the same treatment. If the inflammatory state is considerable, or is attended with fever, venesection will be proper; but this will not often i be the case in any state which can be classed under the head of diarrhcea. Local bleeding with leeches, or cupping in the hepatic and precordial region, will, however, always be proper, and must be carried to such an extent as the urgency of the : symptoms may seem to require. The repetition of this measure several times, after the interval of one or two days, may be requisite; and its effects will be greatly promoted by the frequent use of warm fomentations to the same parts. Mild mer- curial preparations, the best of which is the I hydrargyrum cum creta, will also be proper in j cases of this kind, more especially if the affection I of the liver is primary ; they should be given in [ small doses at bed-time, and followed up next morning by a moderate dose of castor oil or othfr mild purgatives; but care must be taken that the inflammatory condition of the duodenum (if it exist) be removed, or at least mitigated by other means, before the administration of purgatives. Calomel will then have a much more beneficial effect in restoring the healthy condition of the liver. Cooling, saline, and demulcent ptisans constitute the best general remedies in this kind of diarrhcea, and commonly suffice, in conjunction with the means above mentioned and a proper DIARRHOEA [CHRONIC] 637 diet, to restore the patient to health. The proper diet in these and other cases will be mentioned hereafter. 3. In the acute or recent diarrhoea, distinguished by the discharges being chiefly mucous or serous, with little or no admixture of proper fa>ces, all these having been previously evacuated either by the natural efforts or by purgatives administered with this intent, we are no longer to look for re- lief from the employment of cathartics, but from means calculated to allay the irritation which exists in the mucous membrane, and which con- stitutes the disease. These means consist of a proper diet, or the abstinence from all food, the internal use of refrigerants, diluents, demulcents, diaphoretics, and opiates, the local detraction of blood, warm baths or fomentations, and other measures of analogous tendency. The treatment will vary considerably according as the attack is slight or severe, and also according to the nature of the exciting cause. In very mild cases, keep- ing the patient in bed, and restraining him from the use of all kinds of food, with the exception of barley-water,—in small quantities, and this only if there is thirst,—will very often put an end to the attack in twenty-four hours, without any other means. If the attack appears to have ori- ginated in cold or obstructed perspiration, it will be proper to apply the general means found most useful in catarrhal affections, of which the most effective are confinement to bed, in a warm room, and mild saline diaphoretics. If the case is some- what more severe, the application of warm fomen- tations to the abdomen, by means of flannel bags filled with bran and dipped in hot water, will be proper, (they will indeed be proper, though per- haps not absolutely necessary, in the very mildest cases,) together with small doses of mucilage, with or without nitre or the liquor ammoniae acetatis, and an equally rigid system of diet If the diarrhoea does not speedily yield to these mild measures, or if it be accompanied with much grip- ing or painful tenesmus, a small dose or two of laudanum, or of the pulv. ipec. comp. in chalk mixture, will be proper ; or a glyster may be ad- ministered, consisting of not more than a couple of ounces of starch mucilage, and a proportion of opium varying according to the severity of the case. When irritation is not very considerable, these means will almost invariably put an end to the attack in a very short time. But should they not do so, or should the severity of the symptoms at the commencement announce the invasion of a more formidable disease, previously to the use of opiates, six, eight, ten, or twelve leeches, accord- ing to the violence of the attack, should be applied to the anus, and the glyster be afterwards given. The leeches may be applied a second or even a third time, if the complaint proves obstinate. In tome cases general bloodletting may be proper; but this is a measure rarely necessary while the disease remains of such moderate severity as still to justify the application to it of the term diar- rhoea. The internal remedies we are accustomed to employ in the cases where opiates are improper or unnecessary, or in conjunction with these, con- sist almost entirely of the blandest fluids given in small quantities, such as the mucilage of acacia 3d or tragacanth and water, with or without nitre; the chalk mixture with the same substances, small doses of the liquor ammonia? acet, and the like. Indeed, were it not that it is often necessary, for the satisfaction of the patient or his friends, to ad- j minister some medicine internally, the case would j often be better left to nature, after the employment of the more active remedies ; but if medicines are j given, they should be such as are at least harm- | less. We will venture to assure the inexperi- i enced that they will find such means infinitely | more conducive to the recovery of the patient, in the cases now under consideration, than either purgatives, or astringents, or opiates, which we regret to say are so often lavished by those who in their pride of bold practice, as it is termed, are accustomed to regard with scorn the treatment we are now recommending. When the disease is prolonged beyond the space of twenty-four or forty-eight hours, or even during this period, if desire for food is urgent, more nutriment may be allowed ; but this must be in very small quantity, and either liquid or of thesoftcstdeliquescent solids. Of this kind are barley-water, rice-water, arrow-root, sago, weak tea with milk, rice-gruel, weak chicken or veal broth thickened with rice or barley, &c. In the variety of mucous diarrhoea which occurs in certain epidemic constitutions, and in persons of a sluggish phlegmatic habit, and in which the intestinal tube is rather irritated secondarily by its own morbid secretions than primarily, a different kind of treatment is necessary. Both emetics and purgatives are here indicated ; the first to evacuate the contents of the stomach and to stim- ulate its coats to more healthy action ; the last to produce a similar effect on the bowels. Ipecacuan is the best emetic in such cases, and the same medicine, in small quantity, will be very properly combined with rhubarb as a purgative. A useful purgative will also be found in small doses of cas- tor oil combined with a few drops of the ol. tere- binth. When by these means the bowels are unloaded of their morbid secretions, and the mem- brane stimulated to more healthy action, if the diarrhoea still continues it must be checked by mild astringents and tonics, or by small doses of opium. In these cases catechu and kino are found useful; but when such means are necessary, the disease will come under the head of chronic di- arrhoea, the treatment of which we shall now notice. Chroxtc Diarrhoza.—This form of diarrhoea is that which the practitioner is most frequently called upon to treat, and which he finds by far the most difficult to cure. In addition to the in- trinsic severity of the disease, sufficiently evi- denced by its long duration, and perhaps in spite of proper treatment, he has probably to contend against many obstacles to recovery which did not exist, or existed in a much less degree, in the acute disease. The patient may have probably an excellent appetite, and cannot or will not re- frain from food calculated to keep up his com- plaint ; neither can he be restricted in many other particulars which obstruct recovery, but which the violence of the acute disease either forced him to attend to, or its brevity rendered but little irk- some. Chronic diarrhcea may assume all the forms of 638 DIARRHCEA [CHRONIC] the acute variety as far as regards the nature of the evacuations, and most of them may succes- sively appear in the same case ; although, gene- rally speaking, the motions preserve one predomi- nating character, as in the acute disease. It is chiefly in the chronic form, however, that the food appears undigested in the stools ; a circumstance readily accounted for both by the nature of the two cases and the diet respectively used in them. In many cases of diarrhoea which are chronic both as to time and the moderate severity of the symptoms, the disease is found, on close examina- tion, to consist rather of a frequent return of slight attacks of the acute kind, than to be strictly chro- nic, in the usual sense of that term. This is an important distinction, and deserves the best atten- tion of the practitioner. In respect to the treatment of chronic diarrhoea, it may be stated generally, that when the symp- toms assume the general character of any of the forms of the acute disease formerly noticed, the treatment to be had recourse to must be similar in kind, but modified by the degree of severity and other circumstances of the particular case. Other modes of treatment will, however, be often neces- sary, and which would have proved injurious in the acute affection. It is here where the medi- cines properly termed astringents, and also tonics, are applicable, and which are so seldom proper in any of the acute forms. In numerous cases of the chronic disease such remedies are likewise very improper, and we believe that the great art of treating chronic diarrhoea successfully, consists principally in the practitioner having the skill to discriminate such cases as are benefited by purga- tives and astringents, from the very large propor- tion which are injured by them. We think it will not be disputed by any prac- titioner of experience, who has been accustomed to consider diseases more according to their pa- thological relations than as mere subjects of em- pirical prescription, that the greater number even of chronic diarrhoeas depend not so much on any foreign matter applied to the intestinal mucous membrane, as on some intrinsic irritation of this membrane itself; and, consequently, that the treat- ment in all such cases is founded not on the indi- cation of evacuating irritating matters, but on that of allaying organic irritation. In a certain pro- portion of cases, no doubt, such irritating matters are present, and their evacuation is essential to the cure of the disease. Great mischief, however, has arisen from the false notion entertained bv many practitioners in this country, that most diarrhoeas are occasioned by such extraneous sources of irri- tation, and which can only be relieved by purga- tives. We cannot too strongly enter our protest against such a principle as a general rule of prac- tice. The circumstances under which purgatives may be used in recent or acute cases were formerly pointed out; and when similar circumstances exist in the chronic stage, the same treatment will be proper. The accumulation of fieces in the bow- els in conjunction with diarrhoea, will always in- dicate the propriety of purgatives, and they may, in a general way, be considered as not likely to be injurious as long as the stools are feculent The same observation is equally applicable to those cases in which there appears to be a morbid accu- mulation of mucus or other secretions in the in- testinal tube. We do not mean to deny that even when the disease consists essentially in an irritation of the membrane, a purgative may not lessen or relieve it; indeed, we know by experience that this is ac- tually the case, and it is only what might be ex- pected from the known effect of stimulant appli- cations to chronic inflammations of other mucous membranes; but we wish the young practitioner to understand that this practice is to be considered as the exception, not as the rule in the treatment of diarrhoea, and that even when a purgative has relieved the symptoms, it is not to be hastily or often repeated. The repetition of purgatives in all bowel complaints requires much judgment and discretion. Aperients may be considered as fairly applicable in cases in which the irritation is of an inactive kind, or where the disease has proved re- bellious to remedies of a different class. In such cases rhubarb is perhaps the best purgative. Another notion, no less false, and perhaps even still more prevalent among practitioners, is, that a great proportion of chronic diarrhoeas depend on debility or loss of tone of the intestinal membrane, and are only to be relieved or removed by astrin- gents, tonics, &c. Such a state may undoubtedly exist; but we are well assured that the number of chronic diarrhoeas which originate in this cause is extremely small compared with the cases which depend on an irritated or inflamed state of the membrane. On the whole, we wish the young practitiorM/r to understand that he is to proceed to the treat- ment of chronic diarrhoea on the only rational principle of endeavouring to ascertain the precise nature of each individual case before he prescribes for it; that he is to give emetics or purgatives where there is evidence that the bowels are op- pressed or irritated by faecal accumulations or morbid secretions; that he is to give astringents and tonics where the flux seems to be the conse- quence of a debilitated and relaxed state of the mucous membrane; that he is to soothe excessive irritability by opiates; and that he is to remove congestive irritation and inflammation by the means best calculated to effect this object in other parts of the system, namely, by removing all causes calculated to keep up irritation, and by the employment of such means as have the power of directly diminishing the local disease. Our limits will not permit us to enter into the consideration of the characteristic features of each of these dif- ferent kinds of diarrhrea ; but their discovery will not be very difficult to any one who is well grounded in the general principles of pathology, and who will take pains to investigate with atten- tion the history and phenomena of the different cases that come before him. [Attention has been drawn by Dr. Stokes (Lee- I tares on the Theory and Practice of Physic, 1st Amer. edit. p. 87: Philad. 1837,) to a chronic form of diarrhoea, depending upon ulcerations of the rectum, at a short distance from the anus. which may be seen with the aid of the speculum. They occur chiefly in those of broken-down con- stitutions, and in such as have taken a great deal of mercury. The symptoms are—irritation of the i colon, tenesmus, tormina, frequent evacuations, DIARRHCEA [CHRONIC] 639 and generally, during the straining, a little blood i roast mutton. The meat of young animals, as is passed. Dr. Stokes advises, that the rectum i lamb and veal, should be avoided. Beef is too should always be examined, when diarrhcea has j stimulant, and fish is bad on account of the large been of long standing, has resisted a great variety ' quantity of excrementitious matter it leaves in the of treatment, has been combined with tenesmus, | bowels. Animal jellies are generally allowable in and a desire to remain on the night-chair after an evacuation,—which shows irritability of the lower part of the tube ; and when the health does not appear to be so much affected as it naturally should be where there has been long-continued disease of a large portion of the great intestine. Since the writer's attention has been directed to (his pathological cause of chronic diarrhoea, he has met with several cases, which have been treated successfully by touching them, where prac- ticable, with lunar caustic, or by a strong solution •f nitrate of silver—from four to twenty grains to the fluidounce of water.] We shall conclude this article by some further observations on the principal remedies used in diarrhoea. Diet*—In all the forms of diarrhoea, acute or chronic, and whatever be the other kind of reme- dies which are proper, there is one mode of treat- ment which is universally applicable, and which the case where meat is^/ound to agree; but they often are more irritating to the bowels than the muscular flesh of animals. In chronic diarrhcea attention to diet is no less necessary, and in general it will be found that the same kind of food is alone proper. It constantly occurs to us to meet with cases of diarrhoea of many months' standing, or which have lasted even for years, and which are speedily removed by the substitution of a mild unirritating diet for the ordinary food of healthy persons. We will here give the outlines of a recent case of this kind, extracted from the out-patients' journal of a public institution to which the writer is attached, and we introduce it the rather because it is not an uncommon case. May 4, 1821. J. G., gardener, ast 35. Has been affected for two years with his present com- plaints, which constitute that form of diarrhoea commonly termed lientery. During the whole of is the most important of all : this is a proper j the above-mentioned period he has had five or six system of diet. This is so important a part of the treatment, that we have no hesitation in stating that the majority of cases of diarrhoea, both acute and chronic, that are curable, may be cured by it alone. In all cases of acute diarrhcea, and in the large class of chronic cases which depend on irri- tation of the mucous membrane, the food should be very sparing in quantity, of the mildest quality, and such as to leave, after the process of digestion, as little excrementitious matter as possible. In recent attacks of the acute diarrhoea, it is often proper to take no food for the first day, or only mild drinks, containing a small quantity of unir- ritating nutriment, such as barley-water or arrow- root During the subsequent days, the same gen- eral kind of diet must be continued, but may be given in larger quantity or of greater strength. When the irritation is somewhat allayed, on the third or fourth day perhaps, but not earlier, broths may be allowed, but no solid food of any kind, and, least of all, solid animal food is to be per- mitted, until the disease is removed or greatly al- layed. The following may be stated as the order in which the articles of diet will generally be found most proper in such cases : barley-water, arrow- root made with water, sago or tapioca, rice-gruel, oatmeal-gruel carefully strained, light broths, with some of the preceding ingredients. In some cases, more especially the chronic kind, a drier diet is found more suitable, — the liquid food ap- pearing to keep up the diarrhoea; but in all cases the ingesta must be of the mildest quality. Rice is one of the most valuable articles of diet in such cases. It should be well boiled and merely moisten- ed with a little broth. While it is extremely mild and unirritating, rice scarcely leaves any remains to be transmitted along the intestines, and this is the reason why it is generally regarded as astrin- gent As soon as it can be borne, a small pro- portion of the lightest animal food may be tak< n with the rice. Tender chicken is the best to loose stools daily. He has a good, often a craving appetite, but unless he is very particular as to what he takes, he suffers pain, sometimes severe pain, shortly after eating, and a relaxed motion speedily follows. The stools are in general liquid, slimy, dark, and offensive, and frequently contain masses of undigested food. All sorts of hard or solid food disagree, such as tough meats of every kind, pork, cheese, &c, and when taken, appear unchanged in the subsequent motions. More fluid food agrees, such as arrow-root, gruel, rice, broth if not fat, &c. He is much troubled with flatulence, but is never sick at stomach so as to vomit, nor is he thirsty. The tongue is white, with considerable tenderness on pressure, and also distension of the epigastrium ; the urine is clear. There is no particular dryness of skin, and he perspires easily on exertion. He has occasional headach, giddiness, and slight palpitation, and the feet are often cold especially at night. He sleeps well, except when pain is present in the bowels. He has lost eighteen pounds in weight during the last twelve months. Notwithstanding the avow- ed inconvenience produced by certain kinds of food, he does not usually debar himself from them. He also drinks beer, about two pints daily. This man was directed to alter his diet entirely; to give up all kinds of solid food, and to live on broth, jellies, light puddings, rice, and liquid fari- naceous food ; to give up drinking beer; and, in a word, to take nothing which he knew to have the effect of irritating his bowels. He was direct- ed to put his feet in warm water every night. The only remedies prescribed were, ten leeches to the pit of the stomach, and a powder consisting of pulv. tragacanlh c. Jjij, potassa? nit. £)j, to be dis- solved in half a pint of cold water, and taken daily in divided portions. The effect of this change of regimen, (to which the man adhered faithfully) was, that the diar- rhoea ceased within three days, and never return- ed. He w;is not, however, discharged from the begin with; then white game boiled; and then i. books of the infirmary until the end of July, al- 640 DIARRHCEA [CHRONIC] though he had for some time returned to the use of animal food without suffering any inconve- nience : indeed, he said his bowels were then in a better state than he ever remembered them to have been. This man continued well many months after his discharge. In some cases of chronic diarrhoea, however, particularly those in which astringent medicines are found useful, a solid diet of a more stimulat- ing quality, with a moderate proportion of wine, is found much more useful than the bland unirri- tating food above mentioned. In such cases the dry and tonic diet has the effect of producing mo- tions of a more solid kind ; while at the same time it tends at once to restore the lost tone of the bowels and the general strength. In practical medicine we must never follow our pathological principles so far as to be blind to the results of experience; and in diarrhcea, as in every other disease, however we may allow to science the ini- tiatory in prescription, it is the observation of a favourable result alone that can justify persever- ance in any kind of regimen or medicinal treat- ment. Leeches.—In the case above detailed we are disposed to attribute nearly all the good effects to the change of diet; but the application of leeches, even for a single time, was probably of benefit. We judge so from the marked benefit we con- stantly find from their use in this complaint, whether in the acute or chronic form. When the diarrhcea is evidently complicated with a state of irritation or slight inflammation of the mucous membrane of the stomach and small intestines, the treatment should begin with the application of leeches to the epigastrium. If this and the ap- propriate diet fail, then leeches must be applied to the anus, or to this part in the first place, if the diarrhoea is uncomplicated with gastric irritation. For the relief of the inflammatory irritation of the large intestines, there can be no doubt that leeches applied to the anus are greatly more efficient than when placed on the abdomen. This remedy is indeed possessed of remarkable powers in the dis- ease, often working, according to the common expression, " like a charm," even in cases of very long standing and of different external characters. Combined with proper diet, indeed, we are per- suaded that the greater number of diarrhoeas, both acute and chronic, will yield to this method, with little or no aid from other medicine. We have repeatedly known a diarrhoea of long standing, more particularly in the case of infants, cured by a single application of two or three leeches only; and in more obstinate cases it will be found that an instantaneous and marked remission of the symptoms follows every repetition of the remedy. Although, in our own practice, we always com- bine with the use of leeches, in the cases where they are indicated, a proper diet, yet we have had ample evidence of their unassisted powers in checking or removing diarrhteas of great severity and obstinacy. We would add one caution, which may be useful to those not in the habit of making much use of this remedy :—to ensure the full effect, the leeches should be applied immedi- ately to the anus, that is, as close to the mucous i membrane of the extremity of the rectum as pos- , sible. Unless accurate directions are given, j nurses will be apt to mistake our meaning. It has frequently happened to us to find the prescrip- tion of hirudines ano carried into effect by their being applied to the buttock, perineum, or even sacrum. Bathing. — In most of the cases in which an unirritating diet and the local detraction of blood are beneficial, the employment of some form of the tepid or warm bath will be useful. Although the general bath is often indicated, and is the best form of the application, yet in the majority of cases we find that the frequent use of warm fomentations to the bowels by means of flannel bags of bran, with the foot-bath at bed-time, answers completely in promoting the removal of the intestinal irritation. (See Bathing.)* Opiates.—Of the means calculated to assist in the cure by affording temporary relief from pain, as well as by directly allaying the irritated condi- tion of the bowels, no remedy equals the use of opiate injections. In all cases where there is tenesmus with pain and frequent stools, this remedy is to be had recourse to as a means of temporary relief, whatever other plan may be pur- sued for the permanent cure of the disease. Solid opium, or extract of poppy, carefully rubbed down into mucilage, or the pulvis opii, Battley's liquor, or the common tincture, may all be used. Perhaps the pulvis opii is, on the whole, the most conve- nient form ; of which one, two, or three grains may be administered in a couple of ounces of starch mucilage. This may be repeated according to the urgency of the case; but the student is to be earnestly cautioned not to be seduced by the relief often produced by this application, into the neglect of means of more permanent efficacy. Astringents.—It will not, we trust, be imagined, from the manner in which we have recommended the use of the foregoing remedies, that we con- sider the treatment of diarrhoea by the use of astringent medicines, properly so called, as gene- rally either useless or improper. On the contrary, we know that cases of this disease are every now and then met with, that can only be cured by such medicines; and that they are very often necessary, at least as palliatives, in the chronic form of diarrhcea. Sometimes nothing else affords relief. All that we labour to impress on the mind of the young practitioner, or on those who have unfortunately been taught to treat diseases as mere collections of Symptoms, without reference to pathology, is, that there are many kinds of diarrhoea which can be best treated without astrin- gents and without purgatives; and that, the pre- sence of frequent fluid dejections does no more necessarily indicate the use of such remedies, than any other single symptom necessarily indicates a peculiar treatment, without reference to the whole disease of which it is but a part In all cases, before we have recourse to astrin- gents, the state of the patient must be carefully examined into, the nature of the evacuations, the state of the abdomen, &c.; lest some inflamma- tory affection should still remain and keep up the * Riverius sives his own rnse in testimony of the effi cacy of the warm bath in diarrhoea. " Corrcptus sum i diarrhoea biliosa. tanta acrim.uiia praifita ut antim ero. 1 deret, ardoretn<|iie urinie concitaret. Dvsenteria erat in ! prnririrtu. ingressus sMniciipium tepiuum, illico libera- | tus sum.—River. Up. Univ. p. 599. DIARRHCEA [CHRONIC] 641 the diarrhcea. Astringents are a class of remedies which seldom fail to do mischief when they do not do good. They are indicated in the cases where the diarrhoea appears to be kept up bv loss of tone, or by a morbid degree of irritability, not dependent on vascular orgasm or inflammation, in the mucous membrane of the bowels; and they are properly used in all chronic cases which have resisted the means calculated to relieve active irritation, or other known pathological conditions, as noticed above. For the particular forms of astringents most useful in such cases we must refer to writers on Materia Medica, and to the article Astringents in the present work. We can only afford space here for a few observations. The astringent substances from the vegetable kingdom that have been used in alvine fluxes are extremely numerous ; and it is probable that some of those not now included in our pharma- copoeias, or, if included, not much employed, are not the least useful. Catechu and kino are now in most common use, probably not so much be- cause they are in reality the best remedies, as because they are the strongest astringents. They are, however, often very useful in the cases of diarrhoea wherein remedies of this class are in- dicated. Both these substances may be given separately, or in combination with opium or other astringents. One of the most usual forms of pre- scription is the tincture of catechu in chalk mix- ture, combined with equal parts of the tincture of cinnamon. In other cases the watery infusion of catechu answers better, in the form of the infus. catechu comp., and may be given in doses of one or two ounces after every loose motion. Dr. Pemberton had an idea that kino had some peculiar virtues as an astringent; that it did not act as such except diarrhoea were present He therefore gave it the preference to other astringents. His mode of administration was in doses of a scruple made into a bolus with opiate confection. (Treatise on Diseases of Abdom. Vise. pp. 112 and 149.) More recently an extensive series of experiments on the effect of kino in diarrhcea, were made in the hospital of La Pitie, in Paris, by M. Bally. In chronic diarrhcea, unaccom- panied by fever or marks of inflammation in the mucous membrane, the continued use of the re- medy, even for a short time, was found almost invariably effectual in stopping the diarrhcea. In one case of three years' standing it effected a cure. But the most remarkable result of M. Bal- ly's experiments is the alleged fact—that the kino, given in doses of twelve or fourteen grains for several days in succession, succeeded in curing diarrhoeas attended by febrile and inflammatory symptoms. (Med. Gazette, vol. v. p. 700.) We confess we are surprised at such a result. Logwood, tormentil, and bistort were more em- ployed formerly than at present as astringents. We believe the former to be a valuable remedy : the best form of using it is decoction, which may likewise be made the vehicle for more active re- medies. The plantain (plantago) was much used by the older authors; and it and many other vegetables were taken boiled in broths and demul- cent ptisans—a form of medicinal administration too much fallen into disuse in this country. Un- Yox.. I. — 81 3d» ripe medlars were formerly famous for their occa- sional effects in diarrhoea; but we apprehend the cases are few in which they can be recom- mended.* Among the mineral astringents, lime and its carbonate deserve attention, as being in most common use, and as being perhaps not the less useful because they are possessed of only moderate astringency. In certain mild forms of diarrhoea, particularly after the use of purgatives, the pulv. cretse comp., with or without opium according to circumstances, is a very mild and valuable re- medy ; and the mistura cretae, it need hardly be said, is the common and one of the best vehicles for other more powerful astringents. In the more chronic forms of diarrhoea lime-water has been found occasional useful, taken in large quantities as a beverage ; and it is very properly combined in such cases with gum, and often with milk. Equal parts of lime-water and milk, with acacia or tragacanth, is a favourite remedy with many old practitioners. Alum is a medicine given fre- quently in a somewhat similar form, under the name of alum whey, which is made by adding two drachms of the alum to a pint of boiling milk : of this whey a glassful or three or four ounces may be taken as a dose. Alum is also given in a solid form, in bolus or pill, combined with kino, catechu, or opium. The stronger mineral astringents, the acetate of lead and sul- phates of copper and zinc, are occasionally useful, particularly the sulphate of copper; but this re- medy is chiefly applicable in a form of the disease which does not come properly under our notice in this article, the diarrhcea of phthisis. [The solution of persesquinitrate of iron and the tincture of chloride of iron are said to have succeeded when other remedies had failed. (See the writer's New Remedies, 4th edit. p. 294: Phi- lad. 1843, in regard to the former.) The artemi- sia vulgaris, carbo animalis, and ferri ferro-cyanu- retum have been recommended of late years ; but there is no reason for believing that they are supe- rior to other vegetable and mineral tonics. Of late, a mixture called Hope's Mixture, from its proposer, which consists Of nitrous acid and opium, forming a nitrate of morphia, has been highly extolled, in the United States more espe- cially ; but it has not succeeded more frequently with the writer than other remedies suggested by the nature of the case. It is composed as follows : R. Acid, nitros. f.gi; Aquae camphor, f.^viij ; Tinct. opii gtt xl.—M. Dose, a fourth part, every three or four hours. The balsams and turpentines have been much prescribed. Of these the copaiba and the oleum terebinthinae are alone employed at the present day. Nux vomica and its active principle have, * Forestus relates a case of diarrhcea which seems to have been most particularly obstinate, since he inform* us that the poor patient "oinnein suam substantial!] frustra in medicorum ope consiimpsenit, consilii causa, ut ab hoc malo liberari posset," but wliich he (Forestus) cured in a few days by giving him a great quantity «.»f unripe medlars to eat. The same author tells us of a pnti»nt of Spirinchius, who was cured of an equally ob- stinate diarrluea by the same means; but Spirinchius was more fortunate in a richer patient, "qui medico treceutos aureos pro sola inespiloriim praescriptiono nu.- meravit." Forest. Op. tom. iii. p. 47. 642 DIARRHCEA [ADIPOUS.] likewise, been used, and occasionally with great advantage.] In this and other forms of diarrhoea depending on disorganization of the bowels, opiate clysters are commonly found most effectual. A simple form of injection recommended by Van Swieten is also found occasionally beneficial in this dis- tressing complaint: it consists simply of an ounce of treacle or juniper-rob in three or four ounces of warm milk. (Comment vol. ii. p. 394. Diar- rhcea Fe brilis.) In every form of chronic diarrhoea, warm cloth- ing with flannel next the skin, and an additional quantity on the abdomen, in the form of a belt or swathe, is highly useful. In many cases, also, warm galbanum plasters and other warm external applications to the abdomen are very beneficial. This mode of treatment was much used by the older authors. (See Forestus passim.)* It is hardly necessary in all such cases to dwell on the propriety of the patient being lodged in a dry well-ventilated chamber ; or of the advantages of a mild and dry climate. Chronic diarrhcea is, indeed, one of the diseases in which a change to a warmer and drier climate than ours is found most beneficial, (see Climate); and this leads us to notice the fact well known to travellers, and to physicians who have had much to do with travelling invalids, that a journey is almost specific in arresting diarrhcea. John Crampton. John Forbes. Abipotjs Diahkhosa molten grease, the gras fondure of the French, is characterized by a dis- charge of fatty matter from the bowels, sometimes in a fluid state, at others in the form of fatty concretions. Many cases of the latter are re- corded ; and, of late years, attention has been especially directed to the former. In one case related by Sir Everard Home, the fatty discharges might be accounted for by the patient's habit of taking castor oil regularly ; but in other cases, the adipous discharges are evidently at the expense of the system. At times, the discharge is in the form of oil, or semi-concrete matter floating on the top of the feces, and possessed of a fetid odour. The quan- tity evacuated differs greatly. In one case, which occurred to Dr. J. B. Jackson, of Boston, it amounted on the average, in twenty-four hours, to about eight ounces during more than four months. Some fatty concretions, analyzed by Lassaigne and L. Gmelin, had the following constituents : seventy-four parts of an acid fatty matter, in which stearin predominated, eleain and a peculiar acid ; twenty-one parts of a substance analogous to fibrin ; four parts of phosphate of lime and one part of chloride of sodium. In another case, there were, in one hundred parts, sixty of matter simi- lar to spermaceti; thirty of phosphate of lime ; eight of animal matter, and two of loss. In many of the cases of fatty discharge, there was concomitant disease of the liver, pancreas or duodenum; 60 that it was imagined the anomal- *Quibus arijungenda sunt topica, olea, unguenta, lini- -nenta et fotus, ungnenta et irrigationes, ex oleo om- phac. rosaceo, inyrteo, cotoneoruin cum vino adstrin- gente, cerata, &c. Forest, vol. iii. p. 58. j ous secretion might be the product of the pancreat or the liver. On the other hand, in some of the I cases on record, the ducts of the liver and pan- creas have been so obstructed as to preclude the idea of its being the product of either of these vis- cera ; and moreover it has been seen in cases in which there was no reason to believe in the exist- ence of serious disease of those organs. At the age of three years, a little girl was observed to discharge something from the bowels as she walk- ed across the room; this, when examined, was found to be fat in a liquid state, which concreted when cold. " Ever since that time to the pre- sent," (a period of eighteen months,) " she has voided," says Dr. Babington, — the respectable narrator of the case,—" at intervals of ten or four- teen days, the quantity of from one to three ounces, sometimes pure, at others mixed with the fseces: when voided, it has an unusually yellow tinge, and is quite fluid, like oil. Her appetite is good, as well as her spirits, and her flesh firm, her belly rather tumid but not hard." In other cases, the disease appears to have occurred during phthi- sis, hysteria, and other affections; in some instan- ces, oil was discharged from the bladder likewise, and fatty concretions have been taken from the vagina. One of these was examined chemically by Dr. Martius, jr., and found to be composed of fat with some traces of salts. These facts sufficiently establish, that under certain circumstances, and, doubtless, under the influence of particular diseases of the neighbour- ing organs, the gastro-enteric and other mucous membranes may secrete fat from the blood, as the physeter macrocephalus occasionally secretes an enormous quantity of fat under the form of am- bergris :—as much, it is asserted, as one hundred and eighty-two pounds have been found in the body of one of these animals. Treatment. — Where organic disease exists, the efforts of the practitioner may be fruitless; but where the affection coirsists of a vicarious secre- tion from the mucous membrane of the intestines, it may admit of cure. The best mode of manage- ment would seem to be, to attempt a thorough re- | volution in the whole system of nutrition by change of diet, and an entire mutation of all the atmo- spheric and other influences surrounding the pa- tient. Mercurials and other agents belonging to the class of eutrophics,—iodine, and its various preparations, for example,—may be serviceable in this view ; and we may be able to comprehend, that new impressions made on the nerves by the various remedies recommended in hysteria, may ! put an end to the adipous secretion in hysteric ; individuals, by removing the irregularitv of the nervous and other functions, which constitute that protean malady. _ ,_. KOBLEY DUHGL1S0N] DIETETICS. — An organised body, whether of the animal or vegetable kingdom, cannot sus- tain the functions of life without a certain expen- diture, or consumption of the materials of which it consists ; and it is evident, therefore, that every living being, in order to continue its existence, must possess the means of receiving and assimilat- ing to itself foreign matter for the repair of its diurnal waste. It is upon this necessity that the want of food is founded; its judicious administra- DIETETICS. 643 tion must be directed upon principles the know- ledge of which can be alone derived from the sources of physiology and chemistry. The possession of a receiving canal, or internal cavity of some kind, would appear to be exclu- sively characteristic of the animal creation; and Cuvier has distinctly stated that he knows of no animal unprovided with such an apparatus. In plants, on the contrary, which never contain any organ analogous to an internal stomach, the fluid supplies are absorbed by pores on their surfaces ; and although some physiologists have questioned the propriety of so sweeping a generalization, minute investigation has shown, that so far from being real, the instances adduced by them in sup- port of their objection are only apparent excep- tions to this general law of nature. To enter upon this wide field of inquiry would be altogether foreign to the practical objects of the present arti- cle ; nor can we undertake to examine the great diversity of means which Nature employs in the different orders of animals for the conversion of food into nourishment or into blood; we shall only observe that with such nicety are the pro- cesses of waste and supply adjusted, that whatever may be the quantity of food taken, or however the circumstances under which it is consumed may vary, the same individual, after having aug- mented in weight in proportion to the quantity of ingesta, will return in the space of twenty-four hours to nearly the same standard, provided the development of growth, or the existence of disor- dered function, does not interfere with the result. During this period, the food has been decomposed, and re-combined into compounds analogous to those which constitute the organs to which it is carried ; and this would appear to take place, how- ever remote its composition may be from that of the structures with which it is assimilated. It is, however, important to notice that the extent of the digestive cavity bears a relation to the nature of the food it is destined to receive, and by which the animal is designed to be nourished; for the more dissimilar its composition to that of the body it is to recruit, the longer must it remain in its alimentary cavity, and the more complicated must be the. changes which are to perfect its transmu- tation. We thus find that carnivorous animals have generally less capacious and complicated organs than the herbivorous tribes; and that amongst the latter, those that feed upon seeds or fruits, with the exception of the ruminantia, have them less so than those which live upon leaves or the entire vegetable. The digestive canal of man is less capacious and complex than that of other mammalia which live entirely on flesh; whence we may infer that in a state of nature he may be capable of subsisting either on animal or vegetable food, and that he is not only qualified for every diversity but for every admixture of it Thus do we see that, while many savage tribes exist almost entirely on fruits and roots, others are as exclu- sively fed on raw animal flesh. The Hindoos, for instance, live upon rice; the Lombard peasants upon maize ; the West Indian negroes fatten upon sugar, those of Senegal upon gum; while the Es- quimaux gluts himself with the blubber of the seal. It would appear, however, that although Ulan may subsist upon almost every variety of food, he cannot bear with impunity a sudden tran- sition from one species to another. This circum- stance was well exemplified in the eastern part of France in the year 1817, where the failure of the crops occasioned such a famine that the poor were compelled to feed upon whatever vegetable productions could be found : the consequences are stated to have been general anasarca, interruption of the menstrual discharge, a diminution of the ordinary number of conceptions by at least one half, and a permanent injury to the health. Even the sudden return to the use of barley bread, after the continuance of this miserable regimen for three months, M. Gaspard informs us, was not unattended with danger. Spallanzani has satis- factorily shown that animals may be brought to live on food of the most opposite kind, provided the change from their usual diet be gradually ac- complished,— such, for example, as a pigeon on flesh, an eagle on bread, &c. We know that in certain maritime districts of the East, horses are not unfrequently fed upon fish, while on the coast of Coromandel they are fattened upon balls of boiled flesh mixed with grain ; and it is on record that a lamb kept on ship-board was fed with flesh until it refused the grass when afterwards turned into a meadow. Such facts have induced some physiologists, amongst whom we may mention the distinguished name of Dr. Bostock, to consider it probable that all the anatomical varieties in the structure of the stomachs of different animals may be resolved into their mechanical effects upon the aliments submitted to their action; and that, whatever may be the chemical composition of the food, provided it be sufficiently comminuted or triturated, it will be equally acted upon by the gastric juice. We might here ask whether the nature of the digestive solvent itself may not at the same time vary with that of the food which excites its secretion, and whether in this way Nature, if not abruptly called upon, may not adapt her measures to her necessities ? Although it is not our intention to discuss, at any length, the question as to whether Nature originally intended that we should feed on animal or vegetable food, nor to follow the train of those speculative authors who have endeavoured to prove that animal food was not eaten before the deluge, but was introduced in consequence of the deterioration which the herbage sustained on that occasion,—there are, nevertheless, several points connected with the first of these questions which we consider as deserving some notice. Reasoning from the data afforded us by the researches of the comparative anatomist, we are undoubtedly au- thorised in pronouncing man to be an omnivorous animal, and this is perhaps the only generalisation of which the subject is susceptible; Broussonet, however, has ventured so far to refine upon this proposition as to decide upon his being more herbivorous than carnivorous in his nature; and, from the proportion which the different teeth bear to each other, he concludes that his mixed diet | should consist of animal and vegetable food in the I proportion of twenty to twelve. It is, however, | quite clear that no rule of this kind can possibly be established. We have only to consider the different effects produced upon the body by these j two species of food, to perceive that the circum- 644 DIETETICS. stances of climate, season, exercise, habit, age, and individual peculiarity must at once oppose such an admission. As every description of food is converted into blood, and since the flesh and blood of carnivorous and herbivorous animals do not differ very mate- rially from each other, it may be inferred that the ultimate effect of all aliments must be virtually the same; and that the several species can only differ from each other in the quantity of nutriment they afford, in the comparative degree of stimulus they impart to the organs through which they pass, and in the proportion of vital energy they require for their assimilation. Now were the de- gree of excitement which attends the digestion of a meal commensurate with the labour imposed upon the organs which perform it, it is quite clear that less irritation and heat would attend the digestion of animal than of vegetable food; for in the one case the aliment already possesses a com- position analogous to that of the recipient, and requires little more than division and depuration ; whereas in the other a complicated series of de- compositions and recompositions must be effected before the matter can be animalised, or assimilated to the body. But the digestive fever, (if we may be allowed to apply such an expression to a healthy process,) and the complexity of the alimentary changes, would appear in every case to bear an inverse relation to each other. This must depend upon the fact of animal food affording a more highly animalised chyle, or a greater proportion of that principle which is essentially nutritive, as well as upon the immediate stimulus which the nerves receive from its contact. In hot countries, therefore, during the heat of summer, we are, as it were, instinctively led to prefer vegetable food ; and we accordingly find that the inhabitants of tropical climates select a diet of this description. The Brahmins in India, and the people of the Canary Islands, Brazils, &c, live almost entirely on herbage, grains, and roots, while those of the north use little beside animal food. On account of the superior nutritive power of animal matter, it is equally evident that the degree of bodily exertion, or exercise, sustained by an individual, must not be overlooked in an attempt to adjust the proportion in which animal and vegetable food should be mixed. Persons of sedentary habits are oppressed, and ultimately become diseased, from the excess of nutriment which a full animal diet will occasion ; such a condition, by some process not well understood, is best corrected by acescent vegetables. It is well known that artisans and labourers, in the confined manufactories of large towns, suffer prodigiously in their health when- ever a failure occurs in the crops of common fruits. This fact was remarkably striking in the years 1804 and 1805. Young children* and growing youths generally thrive upon a generous diet of animal food; the excess of nutritive matter is consumed in the development of the body, and if properly digested imparts strength without re- pletion. Adult and old persons comparatively require but a small proportion of aliment, unless * The aliment of almost every animal, in its first stage of life, is composed of animal matter; even the gramini- vorous birds are nourished by the yolk of the egg for several days after beiug hatched. the nutritive movement be accelerated by violent exercise and hard labour. Those who advocate the exclusive value of animal food, and deny the utility of its admixture with vegetable matter, adduce in support of their system the rude health and Herculean strength of our hardy ancestors. The British aborigines, when first visited by the Romans, certainly do not appear to have been conversant with the cultiva- tion of the ground, and according to the early writers, Cajsar, Strabo, Diodorus Siculus, and others, their principal subsistence was on flesh and milk ; but before any valid conclusion can be deduced from this circumstance, the habits of the people must be compared with those of their descendants. The history of later times will fur- nish us with a satisfactory answer to those who deny the necessity of vegetable aliment. We learn from the London bills, that scurvy raged to such an excess in the seventeenth century as to have occasioned a very considerable mortality : at that period the art of gardening had not long been introduced. It appears that the most common articles of the kitchen-garden, such as cabbages, were not cultivated in England until the reign of Catharine of Arragon; indeed, we are told that this queen could not procure a salad until a gar- dener was sent for from the Netherlands to raise it. Since the change thus happily introduced into our diet, the ravages of scurvy have been less se- verely experienced. It follows, then, that in our climate a diet of animal food cannot with safety be exclusively em- ployed. It is too highly stimulant; the springs of life are urged on too fast; and disease is the necessary consequence. There may, nevertheless, exist certain states of the system which require such a stimulus, and there may also exist a con- dition of the digestive organs which renders them incapable of assimilating vegetable food ; the phy- sician, therefore, may occasionally confine his pa- tient to an animal regimen with as much propriety as he would prescribe opium or any other power- ful remedy. By a parity of reasoning, the exclu- sive use of vegetable food may be shown to be inconsistent with the acknowledged principles of dietetics, and to be incapable of conveying a nour- ishment sufficiently stimulating for the active ex- ertions which belong to our present civilized con- dition. At the same time, it must be allowed that an adherence to a vegetable diet is usually productive of far less evil in sedentary habits than that which follows the use of an exclusively ani- mal regimen. A very curious chapter might be written upon the adverse opinions which the physicians of dif- ferent ages have maintained as to the importance of dietetic observances for the preservation of health and the cure of disease. Hippocrates was the first who attempted to establish any general principles upon the subject of dietetics ; but ac- curate as he was in all his observations of the phenomena of disease, and admirable as are his precepts for its management, so warped were his notions with regard to the nature of aliments, by an absurd and predominating theory, that, instead of gathering from the stores of his experience any useful information, we find nothing but a mass of the most extraordinary conceits. Assuming as DIETETICS. 645 the directing principle of all his researches, that 1 living bodies contain two elements, differing in ' power but agreeing in purpose, viz. fire and vmter, which, with their consequences, heat and dryness, moisture and cold, he considers as necessary and sufficient for the maintenance of all the functions, — the water nourishing and the fire setting in motion.— he proceeds, after showing that disease '• arises from the deficiency of one or the other of these elements, to enumerate the different articles of diet which, from their heating, drying, moist- ening, and cooling tendencies, are best calculated to counteract such morbid states. He tells us, for instance, that fowls of every kind are drier than quadrupeds, because they have no bladder, and neither secrete urine nor saliva; thereby showing that the heat of the body dries up its moisture. Their eggs, he says, are strong, nourishing, and inflating ; strong, because they contain the germ of an animal,—nourishing, because they nurse it, as it were, with milk,—and infl Uing, because they become dilated from a tiny particle to a large size. Hut it was not to be expected that, anterior to the discovery of the circulation of the blood, or to the existence of chemistry as a science, any rational views could be entertained upon a subject so en- tirely dependent upon such knowledge for its ex- planation. There exists, however, a connection between a class of phenomena which the ancient physicians recognised, and which the moderns appear to have too hastily disclaimed,—we allude to what they termed non-naturuh; so called from their not being essential to the mere nature or constitution of living animals, and which, besides the different aliments, included air, exercise, sleep, the excretions, and the passions of the mind. In the second part of this article, it will be the en- deavour of the writer to point out and enforce upon the mind of the practitioner, the very im- portant relations which obtain between the differ- ent stages of digestion and the non-naturals above enumerated. In modern times, the multiplied resources of pharmacy, and the discovery of new chemical agents, have naturally enough led practitioners to depend upon such remedies for the cure of chronic disease rather than upon a modified plan of diet; while, in the circle of the profession, a certain de- cree of distrust, or we might even add of oppro- brium, has fallen upon such practitioners as have insisted upon its paramount importance. This circumstance easily admits of explanation. In physic a remedy or a practice has never been dis- carded by the regular practitioner but it has im- mediately found a patron in the empiric, who seizes upon it with avidity, in order to convert it to his own advantage, just as the rabble dress themselves in the cast-off' clothes of their supe- riors. The minor writers who have swarmed within the last half century have greatly contributed to throw discredit upon the subject. Nothing cher- ishes the public scepticism, with regard to the efficacy of the medical art, so much as the publi- cation of the adverse and contradictory opinions of its professors upon points so apparently simple and obvious, that every superficially informed per- son constitutes himself a judge of their merits. If a reader is informed by one class of authors that a weak stomach is unable to convert liquid food into aliment, and by another that solid food is injurious to feeble stomachs, he at once infers that the question is one of perfect indifference ; and ultimately arrives, by a very simple process of reasoning, at the sweeping conclusion that the stomach, ever kind and accommodating, indiscri- minately converts every species of food into nour- ishment, and that he has therefore only to consult his own inclination in its selection. On the va- letudinarian, incapable of healthy reflection, and ever seeking for causes of fear and anxiety when they do not choose to come uncalled, such works may have a contrary tendency, and lead him to suspect the seeds of disease in every dish, and poison in every cup. It appears to us that authors have in general laid far too great stress upon the quality of the different species of food, and have condemned particular aliments for those effects which should be attributed to their quantity, and still more per- haps to the circumstances under which they were taken ; their dietetic precepts have therefore fre- quently assumed the air of ascetic austerities, and they have thus represented the cure far more formi- dable than the disease. It has been sarcastically observed by a popular writer, more remarkable for the playfulness of his style than for the sound- ness of his logic, that there exists a more intimate connection between the doctrine of Tertullian and that of many a dietetic practitioner, than is gene- rally supposed; that he is the ascetic intrenched in gallipots and blisters, preaching against beef and porter; terrifying his audience with fire and brimstone in one age, and in the other with gout and apoplexy. Now, while we must all deeply lament that the severity of this sarcasm should have been in some measure sanctioned by the theoretical absurdities of many of our writers, it is impossible that any reasonable person can seri- ously contend that numerous diseases do not arise from an improper management of diet; much less that a judicious regulation of it cannot be render- ed subservient to their cure. To those, however, if such there be, who do«question the importance of dietetics, we have only to observe that they may as well deny the utility of the medical art j altogether, and assert that, in all disorders of func- ' tion, Nature is sufficiently powerful to rectify and cure them, without the intervention of art Un- less this be granted, it is absurd to say that bene- ficial impressions may not be made as well through the medium of the materia alimenturia as through that of the materia medica,- or, to borrow the language of Dr. Arbuthnot, that what we take daily by pounds must not be, at least, as import- ant as what we take seldom, and only by grains j or tea-spoonsful. To get rid of such a difficulty, a class of phi- ! losophers admit the salutary influence of particu- lar aliments in rectifying disorders of function, but deny the necessity of reason or philosophy for the selection or management of them, since they consider that Nature has implanted in us instincts sufficiently strong and intelligible to di- rect us, under all circumstances, to what is salu- j tary, and to warn us from such food as may be injurious. We may observe in reply, that man \ has so long forsaken the simple laws which Na- 646 DIETETICS. ture had instituted for his direction, that it is to be feared she has abandoned her charge, and left him under the control of that faithless guide and usurper, to which civilization has given birth. Appetite, which expresses the true wants of the system, can no longer be distinguished from that feeling which induces us to prefer one species of food to another, and which is the offspring of habit, and the consequence of artificial associa- tions. Nor must it be forgotten that, during dis- ease, the senses frequently lose their tact, and the invalid experiences an appetite for things that would be prejudicial. That the natural relations which subsist be- tween the qualities of food and the impressions made by them on the senses, are changed or de- stroyed by the refinements of artificial life, is a fact supported by many powerful arguments. How many kinds of aliment, originally disagree- able, become pleasant by habit 1 and how many substances, naturally agreeable, become disgusting from the creation of certain prejudices 1 We are acquainted with a lady who is always made sick by eating a green oyster ; the cause of which may be traced to an erroneous impression she received with respect to the nature of the colouring mat- ter. Dr. Fordyce has urged a still more serious and conclusive objection to that hackneyed maxim, " that we ought to live naturally, and on such food as is presented to us by nature," viz., that man has no natural food. It is decreed that he shall earn his bread by the sweat of his brow ; or, in other words, that he shall by his industry dis- cover substances from which he is to procure sub- sistence ; and that, if he cannot find such, he must cultivate and alter them from their natural state. There is scarcely a vegetable which we at present employ that can be found growing natu- rally. Buffon states that our wheat is a factitious production, raised to its present condition by the art of agriculture. Rice, rye, barley, or even oats, are not to be found wild, that is to say, growing naturally, in any part of the earth, but have been altered, by the industry of mankind, from plants not now resembling ther%in such a degree even as to enable us to recognise their relations. The acrid and disagreeable apiurugraveolens has been thus transformed into celery ; and the colewort, a plant of scanty leaves, not weighing altogether half an ounce, has been improved into cabbage, whose leaves alone weigh many pounds ; or into a cauliflower of considerable dimensions, being only the embryo of a few buds, which, in their natural state, would not have weighed many grains. The potato again, whose introduction has added so many millions to our population, derives its origin from a small and bitter root, which grows wild in Chili and at Monte Video. If any of our readers, in the face of such facts, still remain sceptical upon the subject of these metamorphoses, lei them visit the fairy bowers of horticulture, and they will there perceive that her wand has not only converted the tough, coriace- ous covering of the almond into the soft and melt- ing flesh of the peach, but that, by her spells, the sour sloe has ripened into the delicious plum, and the austere crab of our woods into the golden pippin ; that this again has been made to sport in almost euJless variety, emulating in beauty of form and colour, in exuberance of fertility, and in richness of flavour, the rarer productions of wanner regions and more propitious climates. If cultivation can ever be said to have left the trans- formation of vegetables imperfect, the genius of cookery is certainly entitled to the merit of hav- ing completed it; for whatever traces of natural qualities may have remained, they are undoubt- edly obliterated during their passage through her potent alembic. After all, then, experience can alone supply the want of instinct, and form the basis of a rational system of dietetics. Experience, dearly bought experience, has taught us that headach, flatulency, hypochondriasis, and a thousand nameless ills, have arisen from the too prevailing fashion of loading our tables with a host of entremets and hors d'aeuvres, which have too frequently usurped the roast beef of old England. The theorist, in the true spirit of refinement, laughs at our terrors: he admits, to be sure, that the man who eats round the table, " ab ovo usque ad mala," is a terrific glutton, but that, after all, he has only eaten words; for, eat as he may, he can only eat animal matter, vegetable matter, and condiment, either cooked by the heat of water or by that of fire,— figure or disfigure, serve, arrange, flavour, or adorn them as you please. There is not a physician of any practical knowledge who cannot, at once, refute such a doctrine by a reference to facts; every old nurse knows from experience, that cer- tain mixtures produce deleterious compounds in the stomach, although the chemist may, perhaps, fail in explaining their nature, or the theory of their formation. What would such a reasoner say, if he were invited to a repast, and were pre- sented only with charcoal and water ? Would he be reconciled to his fare by being told that his discontent was founded on a mere delusion,—that the difference between them and the richest vege- table viands was merely ideal,—an affair of words, —as, in either case, he would only swallow oxy- gen, hydrogen, and carbon? And yet we will venture to assert that the presumption in such a case would not be more violent, nor more opposed to the just principles of physiology and chemistry, than is the argument by which the sciolist attempts to defend a practice wliich converts our refreshments into burdens, and our food into poison. I. Materia Alimkntahia. Those bodies which have possessed life can alone be strictly considered as affording aliment to ani- mals; and yet there exist a certain number of inor- ganic substances, such as water, common salt, lime, &c. which, although incapable by themselves of nourishing, appear, when administered in conjunc- tion with the former, to contribute essentially to nu- trition. The consideration, therefore, of the mate- ria alimtnlaria necessarily embraces, not only the substantive agents above stated, but those acces- sories which from their modus operandi might properly enough be entitled alimentary adjectives. Under the former division will be arranged all the varieties of animal and vegetable food; under the latter, the class of condiments will merit our attention. The arrangements which different authors have proposed for the classification of alimentary sub- DIETETICS. 647 stances will be found to vary according to the ' particular theory by which each may have been influenced. The chemist investigates the compo- sition of an aliment, and arranges it either accord- ' ing to the ultimate elements of which he supposes it to consist, or according to the proximate princi- ples which he considers to predominate in its composition. The naturalist, on the other hand, merely inquires to what division in his zoological system each article of diet belongs, and assigns to it a corresponding place in his arrangement; while the experienced practitioner is disposed to distri- bute the nutrientia in an order which answers to his notions of their relative nutritive value, or to the supposed facility with which they are dis- solved in the stomach : thus, for example, as he finds from experience that the darkest coloured flesh generally contains more nourishment, while it stimulates the system more powerfully than the whiter kinds, he distributes venison, beef, mutton, hare, &c. into one group, while lamb, veal, and the white meats, such as that of turkey, partridge, pheasant, chicken, &c. he considers as constituting a different class. Chemists have been ever anxious to reduce all nutritious substances to some one or more proxi- mate principles. Halter attempted to resolve them into one elementary jelly. Cullen was of opinion that the matter of nutrition is, in all cases, either oily or saccharine, or what seems to be a combina- tion of both these principles. Fordyce reduced all nutritious matter to mucilage; but since he admits of a farinaceous mucilage, a saccharine mucilage, &c, Dr. Bostock very justly remarks that the inaccuracy with which he may be charged is but of a verbal description. Richerand at- tempted to show that the nutritive principle is in all cases either gummy, mucilaginous, or saccha- rine. Dumas is disposed to regard " mucus" as the principe eminemment nulritif," by which he probably means albumen, since he observes that it forms the basis of our organs. Dr. Prout, whose researches in organic chemistry claim our highest attention and respect, has stated that he considers that there exist three great natural classes or groups, which essentially constitute the ground- work of all organized beings, which he denomi- nates the saccharine, the oleaginous and the albuminous. [The classification of Dr. Prout has been taken by Dr. Pereira (.4 Treatise on Food and Diet, Amer. edit, by Dr. C. A. Lee, p. 38, New York, 1843) as the basis of his own, which includes twelve divisions :—the aqueous,- mucilaginous, or gummy; saccharine, amylaceous, ligneous, pectinaceous, acidulous, alcoholic, oily or fatty, proteinaceous, gelatinous and saline. By the combination of these alimentary principles and simple aliments, our ordinary articles of food, or compound aliments, are formed.] M. Magendie has distributed the nutrientia into nine classes, according to the predominance of one or more of those proximate principles, upon the presence of which modern science has assumed that the nutritive qualities of substances mainly depend. The following is his arrangement: I. Fihrinoi's Alimknts.— Comprehending the flesh and blood of various animals, especially such as have arrived at pubertv ; — venison, beef, mutton, hare. II. Albuminous. — Eggs, &c. III. Gelatinous. — The flesh of young ani- mals ; veal, chickens, calf's foot, certain fishes. IV. Fattt and oilt. — Animal fats, oils, butter, cacoa, &c. -, ducks, pork, geese, eels, &c. V. Caseous. — The different kinds of milk, cheese, &c. VI. Farinaceous.—Wheat, barley, oats, rice, rye, potato, sago, arrow-root, &c. VII. Mucilaginous.— Carrots, turnips, aspa- ragus, cabbage, &c. VIII. Saccharine.—The different kinds of sugar, figs, dates, &c.; carrots. IX. Acidulous.— Oranges, apples, and other acescent fruits. If there be any truth in our dietetic experience, and any natural affinity between the objects of our classification, the theory of their arrangement will be unimportant; for, however greatly the roads of our pursuit may vary, we must all ulti- mately arrive at the same end. The danger of relying upon chemistry alone as our guide arises from the uncertainty in which the elementary na- ture of matter is involved. There can be but little doubt that the supplies by which the bodily waste is recruited are solely derived from the food, for experiments of the most refined nature have shown that no part of the air we breathe is ab- sorbed by the lungs ['!]; but it is more than doubtful whether those substances whicn are con- sidered as the ultimate, or even the proximate, principles of our frame, are supplied to them ready formed by the aliments; or in other words, whether the powers of life do not analyse the matter submitted to them, and by recombining its elements, with which we are probably as yet un- acquainted, produce those compounds which the chemist has been induced to suppose have been merely transferred from the ingesta, in order to be incorporated with the living structure. This is not only a highly curious, but a very important question in dietetics. If the views of the chemist be true, we have only to»ascertain what principles may be excessive or defective in any state of dis- ease, and at once to adopt a diet that may restore the healthy balance: but plausible and encourag- ing as such a theory may appear, an appeal to experience will at once prove it to be a uelusion. The emaciated invalid can no more be restored to his plump contour by oleaginous ingesta, than the rickety child can be cured of a mollities ossium by the administration of phosphate of lime. " Na- ture," says Dr. Prout, " will not permit the che- mist to officiate as her journeyman, even in the most trifling degree ; or in other words, he is as little able to remedy or supply, in a direct man- ner, what is amiss or wanting in organic action, as he is to remedy or supply an injured nerve or muscle ; and the only way in which, for the most part, he can hope to influence her operations, is through the indirect agency of those circum- stances which naturally possess the power of influencing them, and the management and con- trol of which are, to a certain extent, within his power." (Gulstonian Lecture, 1831.) This ad- mission, however, by no means invalidates the utility of chemical inquiries with regard to the 648 DIETETICS. nature of the different articles of diet; for as long as the composition of our diet possesses the power of influencing the constitution of our bodies, it is essential that we should be acquainted with its most minute details. Amongst the numerous chemico-physiological questions which have arisen in connexion with the subject of dietetics, the late speculations of M. Magendie are not the least curious. It has been asserted by this distinguished physiologist that the azote or nitrogen of all the different tissues of the animal body can only be supplied by our food, and, consequently, that no substance which does not contain this principle can support life. In order to acquire some more exact notions on this subject, he submitted several animals, during a necessary period, to the use of food of which the chemical composition was accurately ascertained. We shall present our readers with a short abstract of these experiments, and then explain the different, but not less important, con- clusions which we are prepared to deduce from their results. He took a dog of three years old, fat and in good health, and put it to feed upon sugar alone, and gave it distilled water to drink : no restrictions were imposed as to quantity. It appeared very well in this way of living for the first seven or eight days; it was brisk, active, ate eagerly, and drank in its usual manner. It began to get thin in the second week, although its ap- petite continued good, and it took about six or eight ounces of sugar in twenty-four hours. Its alvine excretions were neither frequent nor co- pious ; that of urine was very abundant In the third week its leanness increased, its strength diminished, the animal lost its liveliness, and its appetite declined. At this period there was deve- loped, first upon one eye, and then on the other, a small ulceration on the centre of the transparent cornea ; it increased very quickly, and in a few days was more than a line in diameter; its depth increased in the same proportion ; the cornea was very soon entirely perforated, and the humours of the eye ran out. This singular phenomenon was accompanied with an abundant secretion of the glands of the eyelids. The dog, however, be- came weaker and weaker; and, though it ate from three to four ounces of sugar per day, it be- came so weak that it could neither chew nor swallow ; for the same reason every other motion was impossible. It expired the thirty-second day of the experiment. M. Magendie opened the animal with every suitable precaution. He found a total want of fat; the muscles were reduced to less than five-sixths of their ordinary size; the stomach and intestines were also much diminished in volume, and strongly contracted. The gall and urinary bladders were distended by their pro- per fluids, which M. Chevreul was called upon to examine. That distinguished chemist found in them nearly all the characters wliich belong to the urine and bile of herbivorous animals; that is, that the urine, instead of being acid as it is in carnivorous animals, was sensibly alkaline, and did not present any trace of uric acid, nor of phos- phate. The bile contained a considerable portion of picromel, a character considered as peculiar to the bile of the ox, and in general to that of her- bivorous animals. The excrements were also examined by M. Chevreul, and were found to contain very little azote, whereas they usually furnish a considerable quantity. M. Magendie considered that such results required to be veri- fied by new experiments; he accordingly repeated them on other dogs, but always with the same conclusions. He therefore considered it proved, that sugar by itself is incapable of supporting dogs. This want of the nutritive quality, how- ever, might possibly be peculiar to sugar; he therefore proceeded to inquire whether other sub- stances, non-azotised, but generally considered as nutritive, would be attended with the same con- sequences. He fed two dogs with olive oil and distilled water, upon which they appeared to live well for about fifteen days ; but they afterwards underwent the same series of accidents, and died on the thirty-sixth day of the experiment. In these cases, however, the ulceration of the cornea did not occur. Gum is another substance that is said not to contain azote, but which is considered as nutritive. To ascertain whether it acted like sugar and oil, several dogs were fed exclusively upon it, and the phenomena did not sensibly differ from those above described. An experiment was then instituted with butter, an animal substance which, like the preceding, is considered as not possessing any azote in its composition. The dog was supported by it very well at first; but in about fifteen days it began to lose flesh and to become weak: it died on the thirty-sixth day, although on the thirty-fourth he gave it as much flesh as it would eat a considerable quantity of which it took for two days. The right eye of this animal presented the ulcerations of the cor- nea. The opening of the body exhibited the same modifications of the bile and urine. In order to make the evidence furnished by the above experiments as complete as possible, after having given to dogs separately, oil, sugar, or gum, he opened them, and ascertained that these substances were each reduced to a particular chyme in the stomach, and that they afterwards furnished an abundant chyle ; whence he argues that, if these different substances are not nourish- ing, it cannot be attributed to the want of diges- tion. We are anxious to give all due credit to the accuracy with which these experiments were per- formed, but we deny the conclusions which this eminent physiologist has deduced from their re- sults. We meet him at once, by questioning the truth of his very first proposition, that sugar, oil, and gum cannot furnish azote. Is there a chemist of the present day who does not believe, although he is unable to prove it by direct experiment, that azote is a compound ? The sugar therefore may furnish its elements, although we cannot detect azote during its decomposition in our laboratories. But let us waive this objection ; we are quite pre- pared to impugn his conclusion on other grounds. What do his experiments prove ? In the first place, the fact which we have before stated,—that an animal cannot bear a sudden and permanent change in its diet without injury; and in the next place, that a highly concentrated diet, or food which does not contain an intermixture of innu- tritive parts, is always injurious. M. Magendie has himself, by subsequent ex- DIETETICS. 649 periments, furnished evidence against his own theory; for a dog confined on a diet of white bread, the gluten of which contains an abundance of azote, perished like those fed on sug-tr or gum. Animals, moreover, which were kept upon cheese, and even upon hard boiled eggs, became diseased, and yet casein is a highly azotised principle, while albumen is considered by Berzelius as the peculiar source of all the animal secretions.* [That the effects were not owing to the priva- tion of azote, Magendie has of late been still more amply satisfied. (Camples Rendus, Aout, 1841.) In the name of a committee appointed to inquire into the nutritive properties of gelatin, he report- I ed, as chairman, that gelatin, albumen, and fibrin — all of which are highly azoted — when taken J separately, nourish animals for a very limited pe- riod only, and in an imperfect manner. They generally soon excite such insurmountable dis- gust, that the animals die rather than partake of • them. These experiments have led to the too hasty conclusion, that the gelatinous tissues are incapable of conversion into blood. " The gelatin- ous substance," says Liebig, (Animal Chemistry, Amer. edit by Webster, p. 124, Cambridge 1842,) "is not a compound of protein: it contains no sulphur, no phosphorus, and it contains more nitrogen or less carbon than protein. The com- pounds of protein, under the influence of the vital energy of the organs which form the blood, assume a new form, but are not altered in composition-; whilst these organs, as far as our experience reaches, do not possess the power of producing compounds of protein, by virtue of any influence, out of substances which contain no protein. Ani- mals, which were fed exclusively on gelatin, the most highly nitrogenized element of the food of carnivora, died with the symptoms of starvation." " In short," he adds, " the gelatinous tissues are incapable of conversion into blood." Yet, it has been shown above, that fibrin and albumen—both compounds of protein — when exhibited alone to animals, nourished them as imperfectly as gelatin. The experiments of Magendie show the neces- sity for variety of food for prolonged animal health and existence. Much, doubtless, depends on the habits of the particular animal or individual, and on the morbid effects excited by completely modi- fying the function of assimilation, as it has been ordinarily practised. It has been long known, that if a person, previously habituated to both animal and vegetable diet, be restricted to one or other exclusively, he will fall off, and become scorbutic; and yet he is capable of subsisting upon either, provided he be restricted to it from early infancy. Of late, great light has been thrown on this subject by the researches of the organic chemist. Tiiese have shown, that the chief proximate prin- ciples of animal tissues, and those that have been regarded as highly nutritious amongst vegetables, have almost identically the same composition. (Liebig, op. cit., p. 100.) They all contain nitro- gen, or are <• nitrogenized." The following tables * The ingenious experiments of Mr. Haichett also Show that albumen is the parent fluid from which other principles may be formed ; he found for instance, that it was convertible into gelatine and fibrine.-PA.*. Trans. 1800. from Liebig exhibit this similarity of constitution in a striking manner :— Animal Proximate Principles, according to Mulder. Carbon, Hydrogen, .. Nitrogen, .. Oxygen, . .. Sulphur, . . . Phosphorus, Albumen. . 54.84 . . 7.09 . . 15.83 . . 21.23 . . 0.68 . . 0.33 . 100.00 Fibrin. . 54.56 . 6.90 . 15.72 . 22.13 . 0.33 . 0.36 100.00 Casein. . 54.96 . 7.15 . 15.80 . 21.73 . 0.36 100.00 Vegetable Proximate Principles, according to Sckerer and Jones. Albumen, from wheat. Fibrin. Casein or Lecumin. Carbon, ... .. 55.01 .. . 54.603 . .. 54.138 Hydrogen, . Nitrogen, . . . . 7.23 . . . .. 15.92 .. . . 7.302 . . 15.809 . . .. 7.156 . .. 15.672 Oxygen, Sulphur, i 21.84 ... . 22.286 . ... 23.034 Phosphorus, 100.00 100.000 100.000 Vol. I___82 3e It has been maintained by Liebig and by others, that nitrogenized or azoted aliments are alone capable of forming organized tissues. These, con- sequently, have been classed by Liebig as plastic elements of nutrition,- whilst non-nitrogenized aliments being, in his opinion, inservient only to respiration, are termed by him elements of respi- ration. All this, however, requires proof, and is combated by what we observe in chylefication. In the small chyliferous vessels, more fat, which is non-nitrogenized, is contained than can be ac- counted for by the fat in the food; and as the chyle proceeds, the proportion of fat becomes less and less, whilst that of the nitrogenized elements increases ; hence, nitrogen must be obtained, and a conversion, doubtless, takes place of non-nitro- genized into nitrogenized elements.] We have said that a certain volume or bulk seems to be a necessary condition of wholesome food; — does not the capacity of the digestive organs sufficiently show that Nature never in- tended them for the reception of highly-concen- trated food ? This truth is still further exemplified by the very sparing manner in which she produces concentrated aliment; the saccharine matter of esculent fruits is generally blended with acidulous and mucilaginous ingredients, and the oleaginous matter is thus combined with the farinaceous, in seeds, kernels, and other substances of this de- scription. The evils arising from the use of a too concentrated diet are well known to the physician; and, if we extend our observations to the domestic animals under our care, we shall derive further evidence of this important fact. A great number of our horses are fed with oats and beans, the nutriment of which is condensed into a much smaller space than it could generally be in natural provender; and these animals, when supported on such food, are consequently liable to various ailments originating from diseased action in the stomach, or from general plethora; in short, it need scarcely be remarked that horses so fed, and unnaturally confined in stables, require to be bled and purged to preserve their lives. The animai 650 DIETETICS. thus abused evidently suffers from acidity, as we find him frequently eating absorbent earths with avidity.* The extraordinary exertions often re- quired of horses render it necessary that they should be better fed than when existing in a more natural state ; and since they do not travel so well with a full stomach, it is also necessary to adopt the use of food in which the nutriment is reduced into the smallest compass. Post-horses and others, whose motion must be rapid, are there- fore chiefly fed with corn alone ; but what is the effect ?—fermentation instead of digestion ; as the intolerable odour which assails us in the stable, under such circumstances, and the decomposed glass of its windows from the sulphuretted hydro- gen acting upon the lead contained in it, suffi- ciently testify. Did it never occur to the physio- logist, that had Nature intended animals to feed only upon the concentrated aliment of gramineous and leguminous vegetables, she would have sup- plied them with an apparatus by which they might separate the chaff and straw from the grain ? These remarks may be applied to man : we shall have occasion to show hereafter that the use Of chocolate, butter, cream, sugar, and rich sauces, without a due admixture of bread, potatoes, and other less concentrated aliment, is invariably at- tended with disordered digestion. Unless the taste be vitiated, there exists an instinctive aver- sion to such food— ■ " the prudent taste Rejects, like bane, such loathsome lusciousness." The Kamtschatdales are frequently compelled to live on fish-oil, but they judiciously form it into a paste with saw-dust, or the rasped fibres of indi- genous plants. Nut ritiveness and Digestibility of differ- ent kinds of Food.—Before we attempt to ap- preciate the value of the different articles of the ma- teria alimentaria, it will be necessary to caution the reader against the popular error of regarding the terms digestible and nutritive as synonymous and convertible. A substance may be highly nutri- tive and yet be digested with difficulty ; that is to say, it may require all the powers of the digestive organs to convert it into chyle, and yet, when so converted, it may afford a principle of highly re- storative energy : this is the case with the fatty and oily elements.-j- On the contrary, there are substances which apparently pass out of the sto- mach with sufficient readiness, but afford but little comparative support to the body. Writers on dietetics have descanted very learn- edly upon what they please to term the perspira- bility and ulkalescency of certain aliments. To the former we are quite unable to attach any pre- cise meaning ; with respect to the latter, we appre- hend that it is intended to express a highly nutri- tive quality, with a certain degree of indigestibi- lity. Heavy and light, as applied to food, are terms equally vague and indefinite, and oiight never to be introduced into writings which aspire to the character of philosophical precision. The observation may be extended to the epithet bilious. It is only necessary to reflect upon the chemi- cal and mechanical processes by which chymi- * The habit of crib biting may perhaps be attributed to such a source. t It has been calculated that an ounce of fat meat af- fords nutriment equal to four ounces of lean. fication is performed in the stomach, to perceive that the digestibility of a substance may depend upon other circumstances than that of its chemi- cal composition. Its mechanical state with regard to texture and consistence, is of the highest im- portance ; and if we attempt to deduce any law upon this subject, from the known solubility of a substance out of the body, we shall fall into seve- ral fatal errors. It will be necessary to investigate this question with some attention, for it not only explains the relative digestibility of aliments, but furnishes the only true basis for a system of skil- ful cookery. The healthy stomach disposes most readily and effectually of solid food, of a certain specific de- gree of density, which may be termed its digestive texture; if it exceed this, it will require a greater length of time and more active powers to com- plete its chymification ; and if it approaches too nearly to a gelatinous condition, the stomach will be equally impeded in its operations- It is, per- haps, not possible to appreciate or express the ex- act degree of firmness which will confer the high- est order of digestibility upon food ;t indeed this point may vary in different individuals ; but we are taught by experience that no meat is so di- gestible as tender mutton : when well-conditioned, its fibre appears to possess that degree of consist- ence which is most congenial to the stomach ; and in this country it is perhaps more universally used than any other animal food. Wedder mut- ton, or the flesh of the castrated animal, is in per- fection at five years, and is by far the sweetest and most digestible. Ewe mutton is best at two years old. Beef appears to be not so easy of digestion ; its texture is firmer, but it is equally nutritive; much, however, will depend upon the period which has elapsed since the death of the animal, and more upon the method of cookery; in short, it would be worse than useless to attempt the construction of any scale to represent the nutritive and digestive qualities of the different species of food : the observations here introduced are merely noticed for the sake of illustrating those general principles whose application can alone afford us any rational theory of diet It will not be difficult to understand why a cer- tain texture and coherence of the aliment should confer upon it digestibility or otherwise. Its con- version into chyme is effected by the solvent power of the gastric juice, aided by the churning which it undergoes by the motions of the stomach; and unless the substance introduced possesses a suitable degree of firmness, it will not yield to such motions : this is the case with soups and other liquid aliments ; in such cases, therefore, nature removes the watery part before digestion can be carried forward. It is on this account that oils are digested with so much difficulty ; and it is probable that jellies and other glutinous matters, although containing the elements of nourishment in the highest state of concentration, are not digested without considerable difficulty ; in the first place, on account of their evading the grap- pling powers of the stomach, and, in the next, in \ Some experiments were introduced fur this purpose by Gosse, of Geneva; but the conclusions deduced from them are by no means satisfactory. He confounds solu- bility v\hh digestibility, which in itself is sullicient to vitiate his reasoning. DIETETICS. 651 consequence of their tenacity opposing the absorp- tion of their more fluid parts. For these reasons the addition of isinglass and other glutinous mat- ter to animal broths, with a view to render them more nutritive to invalids, is a questionable cus- tom. The texture of animal food is greatly influenced by the age, sex, habits, condition, diet, and descrip- tion of death of the animal which furnishes it. In proportion generally to the age, its flesh is coarser and more firm in texture, as every one must have noticed in eating birds. If the flesh of mutton and lamb, beef and veal, are compared, they will be found of a different texture ; the two young meats are of a more stringy, indivisible nature than the others, which makes them harder of digestion. It has been also justly observed that young animals differ from old ones in the distribution of the fat, which in the latter is chiefly collected in masses or layers, external to the mus- cles ; whereas in the former it is more interspersed among the muscular fibres, giving the flesh a marbled appearance, which is always a desirable property of butchers' meat. The texture of food will also vary according to the wild or domesti- cated state of the animal; that of the former is more dense, although highly nutritive. The sex also modifies the quality of the flesh, that of the female being always more delicate and finer-grain- ed than that of the entire male, whose fibres are denser. The influence of the genital organs upon this occasion is very extraordinary ; it is generally believed that the flavour of the female is even im- proved by removing the ovaries, or spaying them, as it is called. Every day the testes are permitted to remain, even though totally inactive with re- gard to their proper functions, injures the delicacy of the veal of the bull calf; and an animal which is not castrated until after puberty always retains much of the coarseness of the entire male. The mode of killing an animal has been considered, from the remotest ages, as capable of affecting the quality of its meat. The flesh of hunted animals is characterized by peculiar tenderness : the same effect is produced by any lingering death. This fact probably explains the policy of those old mu- nicipal laws which ordained that no butcher should offer or expose any bull-beef for sale unless it had previously been baited ; and it is upon the same principle only that the quality of pig's flesh could be improved by the horrid cruelty of whipping them to death, as said to be practised by the Ger- mans. The action of vinegar, administered to an animal some hours before killing it is also known to be capable of rendering its flesh less tough. It is a common practice in the country to give a spoonful of this acid to poultry, when they are intended for the immediate service of the table. Nothing, however, tends more effectually to ameliorate the rigidity of the animal fibre than incipient putrefaction. The length of time that meat ought to be kept after it is killed will neces- sarily depend upon its tendency to undergo the putrid fermentation, and the prevalence of those circumstances which are inclined to favour it The circumstances which have been just enu- merated, as being capable of influencing the tex- ture of our food, and consequently its degree of digestibility, are, however, unimportant when com- pared with the modifying powers of cookery, which we shall now proceed to examine. Cookery.—By cookery, alimentary substances undergo a two-fold change; their principles are chemically modified, and their textures mechani- cally changed. The extent and nature, however, of these changes will greatly depend upon the manner in which heat has been applied to them ; and if we inquire into the culinary history of dif- ferent countries, we shall trace its connection with the fuel most accessible to them. This fact readi- ly explains the prevalence of the peculiar species i of cookery which distinguishes the French table, and which has no reference, as some have ima- gined, to the dietetic theory or superior refinement of the inhabitants. By the operation of boiling, the principles not properly soluble are rendered softer, more pulpy, and, consequently, easier of digestion ; but the meat, at the same time, is deprived of some of its nutritive properties by the removal of a portion of its soluble constituents: the albumen and gelatin are also acted upon; the former being solidified, and the latter converted into a gelatinous sub- stance. If, therefore, our meat be boiled too long or too fast, we shall obtain, where the albumen predominates, as in beef, a hard and indigestible mass, like an over-boiled egg; or where the gelatin predominates, as in young meats, such as veal, a gelatinous substance equally injurious to the diges- tive organs. Young and viscid food, therefore, as veal, chickens, &c, is more wholesome when roasted than when boiled, and is easier digested. Dr. Prout has very justly remarked that the boil- ing temperature is too high for a great many of the processes of cooking, and that a lower tem- perature and a greater time, or a species of infu- sion, are better adapted for most of them. This is notorious with substances intended to be stew- ed, which, even in cookery-books, are directed to be boiled slowly, (that is, not at all,) and for a considerable time.* The ignorance and prejudice existing on these points is very great, and com- bated with difficulty ; yet, when we take into ac- count their importance, and how intimately they are connected with health, they will be found to deserve no small share of our attention. The loss occasioned by boiling partly depends upon the melting of the fat, but chiefly from the solution of the gelatin and osmazone ; mutton generally loses about one-fifth, and beef about one-fourth, I of ite original weight. Boiling is particularly ap- i plicable to vegetables, rendering them more solu- ble in the stomach, and depriving them of a con- siderable quantity of air, so injurious to weak stomachs. But, even in this case, the operation may be carried to an injurious extent; thus pota- | toes are frequently boiled to the state of a dry in- sipid powder, instead of being preserved in that state in which the parts of which they are com- posed are rendered soft and gelatinous, so as to retain their shape, and yet be very easily separated. On the other hand, the cabbage tribe and carrots are frequently not boiled long enough, in which | state they are highly indigestible. In conducting this process it is necessary to pay some attention * Hence it is that beef-tea and mutton-tea are muct ! more calculated for invalids than the broths of these I meats. 652 DIETETICS". lo the quality of the water employed ; thus, mut- ton boiled in hard water is more tender and juicy than when soft water is used ; while vegetables, on the contrary, are rendered harder and less di- gestible when boiled in hard water. By the process of roasting, the fibrine is corru- gated, the albumen coagulated, the fat liquefied, and the water evaporated. As ihe operation pro- ceeds, the surface becomes first brown, and then | scorched, and the tendinous parts are rendered softer and gluey. Care should always be taken that the meat should not be over-done, nor ought it to be under-dressed,- for although in this latter state it may contain more nutriment, yet it will be less digestible, on account of the density of its texture. This fact has been satisfactorily proved by the experiments of Spallanzani; (Spallanzani on Digestion, vol. i. p. 277 ;) and Mr. Hunter observes that "boiled, and roasted, and even pu- trid meat, is easier of digestion than that which is raw." (Hunter on the Animal Economy, p. 220.) Animal matter loses more by roasting than by boiling; it has been stated above, that by this latter process mutton loses one-fifth, and beef one-fourth; but by roasting, these meats lose about one-third of their weight. In roasting, the loss arises from the melting out of the fat, and the evaporation of the water; but the nutritious mat- ter remains condensed in the cooked solid ; where- as, in boiling, the gelatine is partly abstracted. Roasted are, therefore, more nutritive than boiled meats.* The process of frying is, perhaps, the most objectionable of all the culinary operations. The heat is applied through the medium of boiling oil, or fat, which is thus rendered empyreumatic, and therefore extremely liable to disagree with the stomach. By broiling, the sudden browning or harden- ing of the surface prevents the evaporation of the juices of the meat, which imparts a peculiar ten- derness to it. It is the form selected, as the most eligible, by those who seek to invigorate them- selves by the art of training. The peculiarity of the process of baking de- pends upon the substance being heated in a con- fined space, which does not permit the escape of the fumes arising from it; the meat is therefore, from the retention of its juices, rendered more sapid and tender. But baked meats are not so easily digested, on account of the greater retention of their oils, which are, moreover, in an empyreu- matic state. Such dishes accordingly require the stimulus of various condiments to increase the digesting powers of the stomach. [Solui] Articles of Diet. — Were we to follow the steps of preceding writers on dietetics, we should present a catalogue of the nutrientia, and introduce under each article a history of its composition and qualities; but the utility of gene- ral principles is to abbreviate labour, and to class under distinct heads those remarks which were previously scattered and unconnected. We have seen that the nutritive qualities of a substance depend upon its composition ; but that its digestibility may be influenced by various me- * It has been computed that, from the dissipation of the nutritive juices by boiling, one pound of roasted con- lams as much nourishment as two of boiled meat. chanical causes. It is by such tests that we have now to examine the several classes of food, and to assign to the individual bodies which they em- brace their relative value as articles of diet. Milk is the only nutritive fluid with which na- ture has presented us; but if we examine its chemical composition, we shall soon discover that it possesses an ingredient which is instantly coa- gulated in the stomach : so that, in fact, it must be regarded as a mixture of solid and liquid ali- ment ; the latter, however, considerably exceeding the former in quantity, and thereby demonstrating the necessity of a greater portion of fluid than of solid matter, on which the necessity of alimentary supplies is founded. Although recent milk appears as a homogene- ous liquid, it may be resolved, partly by standing, and partly by agents that do not essentially alter the nature of its components, into three proximate ingredients, the cream, curd, and vjhey. 1. The cream rises to the surface of the milk, after it has stood for some hours, and may be skimmed off, and thus separated from it. It ap- pears to possess many of the properties of oil, is smooth and unctuous to the touch, and stains cloth in the same manner as other unctuous sub- stances. By standing for some days it becomes gradually thicker, and at length forms a soft solid, in which the flavour of cream is no longer per- ceived, and that of cheese is substituted in its place. According to the experiments of Berzelius, cream is a compound body, consisting of butter, 4-5 ; cheese, 3-5 ; and whey, 92 parts ; but since the whey holds certain salts in solution, we may consider the whole of the solid matter contained in cream as amounting to 12-5 per cent When cream is agitated, as is done by the common pro- cess of churning, it is separated into two parts ; a thick animal oil, well known by the name of but- ter, and a fluid which possesses exactly the same properties as milk that has been deprived of its cream. This change has been supposed to be owing to the combination of the cream with the oxygen of the atmosphere ; but it takes place, though perhaps not equally well, in vessels from which the air has been excluded. 2. When milk, either deprived or not of its cream, is mixed with certain substances, or allowed to stand till it becomes sour, it undergoes a change which is called coagulation, consisting of its sepa- ration into a solid substance termed curd, and a fluid called whey. This change may be effected by several agents, such as alcohol, gelatine, and all astringent vegetables; by acids and many neutral salts; by gum, sugar, and more particu- larly by the gastric juice. The effect is supposed to arise from the affinity of the coagulating sub- stance for water, the curd, being principally albu- men, having very little affinity for the same; but this theory can hardly explain the operation of the gastric juice : the infusion of a piece of calf's stomach, not larger than a half crown, will coagu- late a quantity of milk sufficient for making a cheese of sixty pounds weight, although the quantity of coagulating matter cannot in this case exceed a few grains. 3. Whey, or the liquid which remains after the separation of the curd, is a thin and almost transparent fluid, of a yellowish-green colour, and DIETETICS. 653 a pleasant sweetish taste. It still contains, gene- rally, a portion both of curd and of butter • the former of which may be separated by a bo'iling heat, in the form of coagulum. The buttery matter also separates by heat, especially if the whey be previously allowed to become sour. Whey contains, indeed, in its recent state; some acetic acid. When whey, which has been de- prived as much as possible of the butter and curd, is slowly evaporated, it yields the peculiar sub- stance termed »sugar of milk," which may be obtained, by clarification with the whites of eggs, in the form of crystals. The presence of the saccharine matter held in solution in whey enables that fluid to undergo the vinous fermentation ; and it is accordingly employed by the Tartars for making a sort of wine, which is called Koumiss. For this purpose mare's milk is selected, as con- taining a larger portion of sugar than that of the cow. Whey also contains several saline bodies, viz., muriate of potass, phosphates of lime and of iron, and sulphate of potasss,- and a peculiar animal matter, which gives a precipitate with infusion of galls, and affords carbonate of ammo- nia by distillation. Although nature has presented us with this compound fluid for the purposes of nourishment, and although it is evident that its several ingre- dients are wholesome, and designed for the various objects of aliment, yet, when separated by art, they are frequently unwelcome to the stomach ; that viscus would appear to dislike the interfe- rence of the cook, in the performance of an ana- lysis which its own powers are so well calculated to effect. We are well assured that the first pro- cess which takes place in the stomach for the chymification of milk, is its separation into curd and whey; and yet the former of these sub- stances, when obtained by art, frequently proves highly oppressive to the stomach, and sometimes occasions obstructions in the bowels. Cheese, again, which is nothing more than the coagulum of milk, pressed, salted, and partly dried, with a portion of butter, which, having been enveloped in the curd, is not afterwards separable, is one of the least digestible of our aliments, and is only adapted to strong stomachs, and to such persons as use great and constant exercise. When toasted, it is still more injurious, from acquiring a tenacity of texture highly hostile to the digestive functions of the stomach. Butter, from its oily nature, is apt to disagree with delicate stomachs, and when rendered empyreumatic by heat produces heart- burn and other distressing symptoms. Whey differs considerably in its dietetic value, according to the method employed for its separation. When this is effected by rennet, it always holds a portion of cream and curd suspended in it, besides its quantity of sugar. It is, therefore, considerably nutritive ; but it is, at the same time, more ace- scent than milk, and hence it is liable to produce flatulence in those whose stomachs are disposed to encourage fermentation. Whey that has been produced by spontaneous coagulation always con- tains less nutritive matter, is more acid, and con- sequently more objectionable, unless, perhaps, as a drink in certain states of fever. From this account of the composition of milk, several properties of the entire fluid may be under- stood. By boiling it, its albuminous part is not coagulated into a mass like the white of an egg, on account of the large quantity of water through which it is diffused ; but a thin pellicle forms on the surface, which, if removed, is immediately replaced by another; and thus the whole of the albumen may be separated in successive portions. The effect of this process is therefore to diminish the nutritive quality of the milk; but it may at the same,time render it more easily digestible. We have known many invalids who could take boiled milk, but were unable to bear that fluid in its natural state. Milk, in its dietetic relations, may be considered as intermediate between animal and vegetable food ; it is easily assimilated, and therefore affords a quick supply of aliment to the system, while it does not excite that degree of vascular action which is produced by other animal matters. Its nutritive powers may be increased by various additions, which have also, on some occasions, the effect of correcting its natural tendency to acidity, and on others, that of obviating the costiveness which it is liable to occasion; such objects are sometimes fulfilled by adding oatmeal gruel to it. In certain states of organic disease, we have found that milk, impregnated with the fatty matter of mutton-suet, is a valuable article of diet: such a repast is best prepared by inserting the suet in a muslin bag, and then simmering it with the milk. Before quitting this subject, it is necessary to observe that there exists some difference in the composition of the milk of different animals. That of the human subject is much thinner than cow's milk ; is of a bluer colour, and contains much more saccharine matter. It also yields a larger proportion of cream, but from which the butter cannot be separated by agitation. It depo- sits a part of its curd by mere repose. Asses' milk bears a stronger resemblance to human milk than to any other; it contains more sugar than that of the cow, and the proportion of curd is so considerable as even to separate on standing, before the milk becomes sour. Goat's milk yields a remarkably thick and unctuous cream, and abounds also in curd. Egtj.s, in point of nutriment and digestibility, may be classed next to milk ; but their qualities will greatly depend upon the manner in which they have been cooked. When raw, they are certainly not so easily digested as when lightly boiled, so as slightly to coagulate their albumin- ous principle .- but if this process be carried too far, they are converted into a hard mass, which requires a long period for their digestion : but this is much accelerated by the use of vinegar as a condiment. They are distinguished by the pecu- liar quality of singularly affecting some stomachs, even in the smallest quantity ; while they do not produce any uneasy impressions on others. We are acquainted with a person who constantly finds an egg to produce uneasiness when his stomach is in the least deranged, but who can eat them with impunity at all other times. It is a notori- ous fact that eggs, when raw, are laxative, and when cooked are apt to produce costiveness. Fish has been generally considered as holding a middle rank between the flesh of warm-blooded animals and vegetable food. It is certainly less 654 DIETETICS. nutritive than mutton or beef; but the health and ( vigour of the inhabitants of fishing-towns evidently prove that it is sufficiently nourishing for all the | purposes of active life : but in order to satisfy the j appetite, a large quantity is requisite; and the appetite returns at shorter intervals than those which occur during a diet of meat. Nor does this species of food produce the same stimulus to the body ; the pulse is not strengthened as after a repast of flesh ; and that febrile excitement which attends the digestion of the more nutritive viands is not experienced. Hence fish affords a most valuable article of diet to invalids labouring under particular disorders; for it furnishes a chyle mode- rately nutritive, but at the same time, not highly stimulant From the nature of its texture, it does not require a laborious operation of the stomach; although it is sufficiently solid to rescue it from those objections which have been urged against liquid or gelatinous food. From the observations just offered upon the nutritive powers of fish, it must follow that such a diet is not calculated to restore power to habits debilitated by disease, and should never be directed under such circumstances, but from the conviction that the digestive powers are unable to convert stronger aliment into chyle. The jockeys who waste themselves at Newmarket in order to reduce their weight, are never allowed meat when fish can be obtained. On account of the low stimulant power of fish, it requires the assistance of condiment; and on this account salt appears to be an essential accompaniment. Fish have been arranged under three divisions, j viz., fresh-water fish, salt-water fish, and shell- fish; but, since the value of these animals as I articles of food has an intimate relation to the | colour and texture of their muscles, and to their gelatinous or oily qualities, it will be expedient to I consider their several varieties with reference to such conditions. Turbot, cod, whiting, haddock, flounder, and sole, are the least heating of the more nutritive species; and the flakiness of the fish, and its opaque appearance after being cooked, may be considered as true indications of its good- ness ; for when the muscles remain semi-transpa- rent and bluish, after sufficient boiling, we may reject it as inferior in value, or not in season. When the fish is in high perfection, there is also a layer of white curdy matter, resembling coagu- lated albumen, interposed between its flakes. The whiting is well adapted to weak stomachs, on ac- count of the little viscidity which it possesses ; it is, at the same time, tender, white, and delicate, and conveys sufficient nutriment with but little stimulus to the system. The haddock much re- sembles it, but is firmer in texture. Cod has a more dense fibre than the two former, and con- tains also more glutinous matter: it is an excel- lent aliment, but upon the whole is not quite so digestible as whiting or haddock. It is generally preferred when large ; but such fish are frequently coarse. The haddock is certainly better when it does not exceed a middling size. Turbot is an excellent article of food; but it is usually render- ed difficult of digestion by the quantity of lobster sauce with which it is ealen. Sole is tender, and yet suffi. iently firm ; it is therefore easy of" diges- tion, and affords proper nuttiment to delicate sto- machs. It is necessary to state that every part of the same fish is not equally digestible ; and it unfortunately happens that those which are con- sidered the most delicate are, at the same time, the most exceptionable : the pulpy, gelatinous skin of the turbot, and the glutinous parts about the head of the cod, are very apt to disagree with invalids. Salmon may, perhaps, be considered the most nutritive of our fish; but it is heating and oily, and not very digestible : and persons, even with strong stomachs, are frequently under1 the necessity of taking some stimulant to assist its digestion. The addition of lobster sauce ren- ders it still more unwholesome: the best condi- ment that can be used is vinegar. As connected with the time of spawning, the season of the year has the most decided influence upon the quality of salmon. It is in the highest perfection, or in season, as it is termed, some time previous to its spawning; the flesh is then firm and deli- cious ; whereas, after this event, it is for some time unfit for food. Salmon trout is not so rich and oily as the salmon ; although, therefore, it is less nutritive, it is at the same time less heating and more digestible. Eels are extremely objec- tionable, on account of the large proportion of oil which they contain. From these observations, the value of fish may be appreciated, and the qualities which entitle them to election easily un- derstood. Firmness of texture, whiteness of mus- cle, and the absence of oiliness and viscidity are the circumstances which render them acceptable to weak stomachs. Shell-fish have been greatly extolled by some physicians as nutritive and easily digestible arti- cles of food. It will be necessary to examine this question by the application of those principles which we have endeavoured to establish. Oys- ters would appear to enjoy a reputation which they do not deserve ; when eaten cold they are frequently distressing to weak stomachs, and re- quire the aid of pepper as a stimulant; and since they are usually swallowed without mastication, the stomach has an additional labour to perform, in order to reduce them into chyme. When cook- ed they are still less digestible, on account of the change produced upon their albuminous principle. It is, however, certain that they are nourishing, and contain a considerable quantity of nutritive matter in a small compass. It is equally clear that oysters have occasionally produced injurious effects, (Medical Transactions of the College of Physicians, vol. v.) ; these have been attributed to their having lain on coppery beds, but this idea is entirely unfounded, and arose merely from the green colour which they often acquire, the cause of which is now generally understood, being some- times an operation of nature, but more generally produced by art, by placing them in a situation where there is a great deposit from the sea, con- sisting of the vegetable germs of marine confervx and fuci, and which impart their colour to the oyster. For this object the Dutch formerly car- ried oysters from our coasts, and deposited them on their own. Native oysters, transported into the Colchester beds, soon assume a green colour. Where this food has produced a fit of indigestion, it has evidently arisen from the indigestible nature of the oyster, and the state of the individual's stomach at the time; and had such a person in- DIETETICS. 655 dulged to the same amount in any equally indi- gestible aliment, there can be no doubt but that he would have experienced similar effects. Oys- ters cast their spawn, which the dredgers call the ipat, m the month of May, after which they are sick and unfit for food ; but in June and July they begin to mend, and in August they are perfectly well. We therefore see the cause of their going out of season, and discover the origin of the old maxim, that an oyster is never good except when there is an r in the month. Lobsters are certainly nutritive ; but they are exposed to the same ob- jection on the ground of indigestibility ; and such has been their effect upon certain stomachs, as to have excited a suspicion of their containing some poisonous principle : they have been known to occasion pain in the throat, and, besides eruptions upon the skin, to extend their morbid influence to the production of pain in the stomach, and affec- tion of the joints. As found in the London mar- ket, they are generally underboiled, with a view to their better keeping; and in that case they are highly indigestible. The same observations apply to the crab. Shrimps are a species of sea crab, which vary in their colour and size, and are con- sidered easier of digestion than the preceding arti- cles. The mussel is a species of bivalve which is more solid, and quite as indigestible as any animal of the same tribe. The common people consider them as poisonous, and, in eating them, take out a part in which they suppose the poison princi- pally to reside. This is a dark part, which is the heart, and is quite innocuous: the fact, however, is sufficient to prove that this species of bivalve has been known to kill; but probably not more frequently than any other indigestible substance. Our annals abound with instances of the delete- rious properties of melon, cucumbers, &c. and yet no one will contend that any poison, properly so called, resides in such vegetables. The peculiar cutaneous efflorescence which is produced by the imperfect digestion of shell-fish, has been observed to occur more frequently in cases where the fish has been stale or tainted, although it also happens where no such error can be suspected. It has been usual to attribute all the cutaneous affections which follow the liberal use of fish as depending upon the sympathy of the skin with the stomach. This, we believe, is in general the true explanation, since the effect is merely temporary ; and when the process of digestion is finished, it departs. Its departure may even be hastened by the operation of an emetic removing the noxious aliment. At the same time the fact must not be overlooked, that the oily principle upon which de- pends the odour of certain fish, is absorbed from the alimentary canal, and carried into the blood ; this is evident from the peculiar flavour of the flesh of certain birds which live upon fish. It is also well known that persons confined for any length of time to a diet of fish secrete a sweat of a rancid smell. It is not, therefore, improbable that certain cutaneous diseases may be produced, or at least aggravated, by such diet; and in hot climates this effect may be less questionable. The priests of Egvpt may therefore have b. en j ro- hibited from eating fish upon just principles, n order that the leprosy might be averted ; and the great legislator of the Jews was, no doubt, influ- enced by some such belief, when he framed his celebrated prohibition. (Leviticus, xi. 9—12.) It is usual to add various condiments to fish, and many kinds of fish are doubtless thus rendered more digestible, by a necessary stimulus being af- forded to the stomach ; but rich sauces are ever to be avoided by the valetudinarian. Vinegar and salt, perhaps, form the best additions. The mode of cooking fish is another circum- stance of some importance. Frying them in lard or oil is an objectionable process: in general, the process of boiling is best adapted for rendering them wholesome. Stewed fish, with all the usual additions of glutinous and stimulant materials, are extremely injurious to dyspeptics. Birds*—There exists a great variety in the qualities of the food which is furnished by this class of animals, with regard to nourishment, sti- mulus, and digestibility : the whiter meat of do- mesticated birds, as the wings and breasts of chickens, contains less nutriment, and is less di- gestible than that which is furnished by wild birds, as the partridge, &c.; but the former is, at the same time, less stimulant and heating than the latter. These are the circumstances which are to direct the medical practitioner in his opinion. No general rule for the choice of either spevies can be established; it must be determined by the par- ticular condition of the patient, and the effect which the aliment is intended to produce. The same observation will apply to the flesh of quadru- peds; that which is dark-coloured and contains a large proportion of fibrin, as venison, &c. is easily disposed of by the stomach, and a large quantity of highly stimulating chyle is produced from it I The whiter meats are, on the contrary, detained longer in the stomach, and furnish a less stimu- 1 lant chyle. The former, therefore, will be more J easily digested by weak persons, while the latter will frequently run into a state of acetous fer- mentation ; but they may, nevertheless, be pre- ferable on many occasions, inasmuch as they im- part less stimulus to the general system. We see, therefore, the folly into which many popular writers have fallen, of stating such or such an arti- cle as being wholesome or otherwise; as the wholesomeness of an aliment must depend upon its fitness to produce the particular effect which the case in question may require. Van Swieten has justly said, that "to assert a thing to be wholesome, without a knowledge of the condition of the person for whom it is intended, is like a sailor pronouncing the wind to be fair, without knowing to what port the vessel is bound." Farinaceous Aliments.—The flour of wheat contains three distinct substances; a mucilaginous saccharine matter, starch, and a peculiar sub- stance, possessing many of the properties of ani- mal matter, termed gluten. It is to the quantity of this latter ingredient that wheat flour possesses so decided a superiority over that of barley, rye, or oats, for from these latter grains much less gluten can be extracted. It furnishes by far the best ingredient for making that important article of diet, bread; although it may also be made of all the various sorts of grain, as well as of ches- 1 nuts, of several roofs, and of the potato. We shall first describe the nature of wheaten bread, j and then compare it with that produced from 656 DIETETICS. other substances. The first process for rendering farinaceous seeds esculent, is to grind them into powder between mill-stones : the meal thus pro- duced is purified from the husk of the seed, or bran, by the operation of sifting or bolting ; and it is then denominated flour. This, when mixed with water or milk, undoubtedly possesses the power of nourishing the body ; but in this raw state it would not be sufficiently digestible; it would clog the stomach, and oppose those actions which are essential to chymificatioii. The appli- cation, however, of heat renders the compound more easy to masticate as well as to digest; whence we find in the earliest history a reference to some process instituted for the purpose of pro- ducing this change, although the discovery of the manufacture of bread, simple as it may appear to us, was probably the work of ages. It has been just stated that wheaten flour is the best adapted for making bread, that is to say, loaf bread ; this depends upon the greater qtiantity of gluten which it contains, and which operates in a man- ner to be presently explained. The first stage of this process of panification consists in mixing the flour with water, in order to form a paste, the average proportion of which is two parts of the water to three of the flour ; but this will neces- sarily vary with the age and quality of the flour: in general, the older and the belter the flour, the greater will be the quantity of water required. This paste may be regarded as merely a viscid and elastic tissue of gluten, the interstices of which are filled with starch, albumen and sugar. If, then, it be allowed to remain for some time, its ingredients gradually re-act upon each other, the gluten probably performing an important part; by its action on the sweet principle, a fermentation is established, and alcohol, carbonic acid, and lastly acetic acid, are evolved. If the paste be now baked, it forms a loaf full of eyes, like our bread, but of a taste so sour and unpleasant that it cannot be eaten. If a portion of this old paste, or leaven, as it is called, be mixed with new-made paste, the fermentation commences more imme- diately, a quantity of carbonic acid is given off, but the gluten resists its disengagement, expands like a membrane, and forms a multitude of little cavities, which give lightness and sponginess to the mass. We easily, therefore, perceive why flour, deficient in the tenacity which gluten im- parts to it, is incapable of making raised bread, notwithstanding the greatest activity may be given to the fermentative process by artificial ad- ditions. Where, however, leaven has been em- ployed, the bread will be apt to be sour, in con- sequence of the great difficulty of so adjusting its proportion, that it shall not by its excess impart an unpleasant flavour, nor by its deficiency ren- der the bread too compact and heavy. It is for such reasons that in this country we employ barm; a ferment which collects on the surface of fermenting beer. It appears that we are indebted to the ancient Gauls for this practice. In Paris it was introduced about the end of the seventeenth century; the Faculty of Medicine, howevi r, declared it to be prejudicial to health, and it was long before the bakers could convince the public that bread baked with barm was superior to that of leaven. A great question arose among chemists as to the nature l of this barm that could produce such effects, and elaborate analyses were made, and theories de- | duced from their results ; but all these ingenious , speculations fell to the ground, when it was found that barm, dried and made into balls, would an- swer every purpose; the bakers imported it in such a form from Picardy and Flanders, and when again moistened, it fermented bread as well as the recent substance. The presence, therefore, of carbonic acid, water, acetic acid, and alcohol, could not be essential, for these ingredients were separated by the process of its preparation. At length it was discovered that gluten, mixed with a vegetable acid, produced all the desired effects; and such is the nature of leaven, and such is the compound to which barm is indebted for its value as a panary ferment. After the dough has suffi- ciently fermented, and is properly raised, it is put into the oven previously heated, and allowed to remain till it is baked. The mean heat, as ascer- tained by Mr. Tillet, is 448°. When the bread is removed, it will be found to have lost about one-fifth of its weight, owing to the evaporation of water ; but this proportion will be varied by the occurrence of numerous circumstances which it is not easy to appreciate. Newly-baked bread has a peculiar odour as well as taste, which are lost by keeping : this shows that some peculiar substance must have been formed during the ope- ration, the nature of which is not understood. Bread differs very completely from the flour of which it is made, for none of the ingredients of the latter can be discovered in it; it is much more miscible with water than dough ; and on this circumstance its good qualities, most probably, in a great measure depend. It is not easy to ex- plain the chemical changes which have taken place. It appears certain that a quantity of water, or its ele- ments, is consolidated and combined with the flour; the gluten, too, would seem to form a union with the starch and water, and thus to give rise to a compound upon which the nutritive qualities of bread depend. Unleavened bread consists of a mixture of meal and water, formed into a firm and tough cake, made as thin as possible, to favour its drying, and sometimes with the addition of butter, to render it more soluble, friable, and porous ; but it renders it sourer, and more apt to produce acidity on the stomach. Of the unleavened sorts of bread, bis- cuit is by far the best; and in all cases where leavened or fermented bread does not agree, its use cannot be too strongly advocated. The different sorts of bread to be met with in this country may be considered under three classes : viz. white, wheaten, and household. In the first, all the bran is separated ; in the second, only the coarser; in the third, none at all: so that fine bread is made only of flour, wheaten bread of flour and a mixture of the. finer bran, and household of the whole substance of the grain, without taking out either the coarse bran ■ or fine flour. It is necessary for the medical prac- titioner to understand these distinctions; for it will be proved that an important dietetic fact is connected with them. The tendency of starch upon the bowels is astringent Bread, therefore, which is made of the whitest flour is apt to ren- der them costive 5 but this is counteracted by the , presence of bran, the scales of which appear to DIETI exert a mechanical influence upon the intestines, and thus to excite them into action. The French have many varieties of bread, in which eggs, milk, and butter enter as ingredients. They are also in the habit of adding ammonia to the dough ; which, during its evaporation in the oven, raises it, and thus adds to its sponginess. Barley-bread has a sweetish but not an un- pleasant taste; it is, however, rather viscid, and is less nutritive, as well as less digestible, than wheaten bread. It is common to mix peas-meal with the barley, which certainly improves the bread. Rye-bread is of a dark brown colour, and is apt to lie heavy on the stomach ; it is also liable to create acescency and purging; but it ap- pears to be highly nutritive. In some of the in- terior counties of England, where their bread is often manufactured from oatmeal, there is a mode of preparing the meal by making it sour; the bread, instead of being hard, is thus rendered of a soft texture, and from its moderate acidity is wholesome to strong persons: but invalids should, if possible, avoid it. In bread, however, this grain is more usually in an unfermented state, or it is made into flat, thin cakes, which are baked or roasted. It is evident, from the health and vigour of the people who use this grain as a principal article of diet that it must be very nutritive; but the stomach will require some discipline before it can digest it. In those unaccustomed to such food, it produces heartburn; and it is said to oc- casion, even in those with whom it agrees, cuta- neous affections. In times of scarcity, potatoes have been made into bread ; but they contain too much mucilage in proportion to their starch to afford a good article : the bread thus produced is heavy, and apt to crumble into powder; effects which are obviated by mixing a certain quantity of wheat-flour with the potatoes. Rice will also serve the purpose of making very good bread; but like the potato, it requires the addition of some flour. It is said by some that bread made of different kinds of grain is more wholesome than that made of only one sort, as their qualities serve to correct one another. This is certainly the. case with that which is commonly called brown bread, and which is made of a mixture of wheat and rye flour ; the former, being of a more starchy nature, and apt to produce costiveness, while the latter often proves too laxative: a due proportion of each, therefore, must furnish a de- sirable compound. The importance of bread, as an article of diet, will be easily deduced from the principles upon which the digestion of food in the stomach is ex- plained. In addition to ite nutritive qualities, it performs a mechanical duty of some importance. It serves to divide the food, and to impart a suit- able buik and consistence to it; it is, therefore, more necessary to conjoin it with articles contain- ing much aliment in a small space, than where the food is both bulky and nutritive. The con- centrated cookery of the French is rendered much more wholesome from the large quantity of bread which that people use at their meals. Bread should never be eaten new ; in such a state, it swells like a sponge in the stomach, and proves very indigestible. Care should also be taken to obtain bread that has been duly baked. Unless Vol. I. —83 TICS. 657 all its parts are intimately mixed, and the fixed air expelled, it will be apt, in very small quanti- ties, to produce acescency and indigestion. After stating the advantages of bread, it is ne- cessary to make a few observations upon the evils which it may occasionally produce. In certain diseases it evidently produces a tendency to acidi- ty ; we have daily instances of this fact in chil- dren, in whom acidity and much alimentary dis- turbance follow its use. Shebbeare goes so far as to say that the rickets are so common in France only because the quantity of bread given to chil- dren is excessive; which, by its acidity, destroys the calcareous substance of the bones, and. reduces them to a state of cartilage. This is mere idle speculation, which is in direct variance with the received opinions upon this subject. Where acidity occurs, the bread should be toasted, or well-prepared biscuit substituted. Much has been said and written upon the sub- ject of the adulteration of bread ; but we are in- clined to believe that the evils arising from such a practice have been greatly exaggerated. It is certain that the inferior kinds of flour will not make bread of sufficient whiteness to please the eye of the fastidious citizen without the addition of a proportion of alum. It has been also found that unless this salt be introduced into the flour, the loaves stick together in the oven, and will not afterwards separate from each other with that smooth surface which distinguishes the loaf of the baker. This circumstance is probably owing to the action of the alum upon the mucilage of the flour, which it coagulates. It has been said that the smallest quantity that can be employed for ! these purposes is from three to four ounces to two hundred and forty pounds of flour. It cannot be denied that the introduction of a portion of alum into the human stomach, however small, may be prejudicial to the exercise of its functions, and par- ticularly in dyspeptic invalids. It was found by Mr. E. Davy, of Cork, that bad flour may be made into tolerable bread by adding to each pound from twenty to forty grains of the common carbonate of magnesia. Besides bread, several other preparations are made by the solidification of flour, such as pud- ding, pancake, &c. The most digestible pudding is that made with bread or biscuit and boiled flour: batter pudding is not so easily digested; and suet pudding is to be considered as the most mischiev- ous to invalids in the whole catalogue. Pancake is objectionable on account of the process of fry- ing imparting a greasiness to which the dyspeptic stomach is not often reconciled. All pastry is also objectionable : we believe that one half at least of the cases of indigestion which occur after dinner-parties may be traced to this cause. Many persons entertain a strange prejudice in favour of pudding, and appear as if they con- sidered it to possess a balsamic virtue, or some property by which the digestion of other aliment is expedited. If ever such a diet has served the valetudinarian, it must have been by excluding I less stimulating food, and not by any virtue ad- herent in the pudding itself. Amongst the farinaceous aliments, the potato I holds a distinguished rank; but its digestibility | greatly depends upon its kind, and the nature of 658 DIET the cookery to which it is subjected. The species which is known by the name of waxy potato should be shunned by the dyspeptic, for it is so indigestible as to pass through the intestines in an unaltered state. The same objection applies to the young or new potato. The mealy kind more readily yields to the powers of the stomach, and affords a healthy nutriment: but to the dyspeptic, we have generally found this vegetable, in all its states, to be injurious; if e\er allowed to such patients, it is worthy of remark that roasting is preferable to every other form of cookery. The process of mashing certainly does not contribute to its digestibility. If boiled, care should be taken that it is not over-done; for in such a case it is deprived of its nutritious qualities. Rice is the general aliment of the people of the East, with whom it answers the same purposes as bread does with us. As it is not much disposed either to acescency or fermentation in the stomach, it furnishes a wholesome aliment when mixed with other food ; but if taken in large quantities by itself, from its low degree of stimulant proper- ties, it is apt to remain for a length of time in the stomach: this effect is greatly increased by pro- tracted boiling. Where the stomach is in a state of relaxation and debility, it ought not to be taken without condiment; it is, for this reason, found necessary in the warmer climates to conjoin it with a considerable quantity of warm spices. There formerly existed a prejudice against its use, from a belief that it had a tendency to produce blindness. It is scarcely necessary to state that such an idea has no foundation in truth. It is generally considered as astringent, and is, there- fore, a popular remedy for diarrhoea; no astrin- gent principle, however, has yet been discovered in its composition, and it is probable that it owes its virtues on such occasions to the mild and bland mucilage, with which it abounds, shielding the intestines from acrimonious humours. There are various other aliments in domestic use which owe their qualities to starch, such as sago, tapioca, arrow-root, &c. From the mucila- ginous form in which they are usually adminis- tered to invalids, they are not so digestible as is generally supposed; but where the stomach re- jects more substantial food, they are useful in themselves, as well as proper vehicles for the ad- ministration of vinous stimulants. The leguminous productions, or pulses, may be considered as constituting the second division of farinaceous aliment. They differ little from grains, except in affording a more unctuous flour, which forms a milky solution with water, owing to the presence of an oily matter. Although they are highly nutritive, they are certainly more indi- gestible than seeds, and the bread they afford is apt to occasion flatulence, and to lie heavy on the fctomach. The use, therefore, of this species of food is more circumscribed than that of the fari- naceous seeds; it is principally confined to the lower classes, and to those possessing strong powers of digestion. In dyspeptic habits they ought on no account to be allowed; the symptoms of uneasiness which they produce in such persons are often alarming : flatulence and colic are the common consequences of their action. Pulses *re employed in two very different states; in an TICS. | early stage of their growth, when they are succu- | lent; and when all their parts have reached ma- | turity: in the former condition they are frequently acceptable to the stomach ; but in the latter they are only calculated for those who have strong digestive powers. Peas form a wholesome and light food when green and young, but when full grown and dry they are very indigestible: in this latter state they contribute, in a remarkable degree, to the genera- tion of gas in the intestines. In the form of pudding they are, if possible, still more objection- able ; for, to the bad qualities which depend upon their composition, are thus added those which arise from tenacity of texture. Beans, like peas, are comparatively wholesome in their immature state. The kidney-bean, being eaten with its pod, is not so flatulent as other pulse : when well boiled, it is easy of digestion, but not very nutri- tive. Nuts are generally supposed to have constituted the earliest food of mankind; and they still fur- nish, in some countries, a considerable source of food. In this country they are principally known as an article of the dessert, although on some occasions they are eaten with our food. With regard to composition, the Chestnut may perhaps be considered as more nearly allied to the pulse than to the nut tribe, since it affords no oil by ex- pression, and from its farinaceous qualities it may I even be made into bread, although it is heavy and indigestible. Its nutritive power must be con- siderable, since it forms the chief food of the lower orders of the plains in Lombardy ; and it has been conjectured that it was the acorn so fre- quently mentioned iii ancient history and tradi- tion. When eaten after dinner, an indulgence which can only be conceded to the most robust, it ought to be previously roasted ; its digestibility is also increased by being kept for some time after it has been gathered. It is at the same time thus rendered more palatable by the greater evolution of its saccharine principle. The evils which may arise from the use of the chestnut are still more likely to occur after the ingestion of nuts, for they are more oily, as well as more viscid and glutinous : when eaten, they should always be accompanied with suit; but it would be wise to banish them entirely from our tables. Esculent Roots.—These are of two kinds; those used as food, and those which principally answer the purposes of condiment or seasoning. Under the first division may be classed turnips, cari-ots, parsnips, Jerusalem artichokes, radishes, j &c, many of which, it will be seen, are seldom j used solely for aliment, but are rather brought to our tables to qualify our animal food. Under the second division may be arranged onions, garlic, horse-radish, &c. It will be necessary to offer a few observations upon the qualities of these seve- ral roots. The carrot, from the quantity of saccharine matter which it contains, is very nutritive and slightly laxative; but it also possesses a large pro- portion of fibrous matter, which in some stomachs prevents the digestion of the root, and it passes I through the bowels with but little change : to j obviate this effect, it ought to be very thoroughly DIETETICS. 659 boiled, and it should be eaten when young. It appears to have been introduced by the Flemings in the reign of Elizabeth. The turnip is a very excellent vegetable, and, although it has the cha- racter of being flatulent, it is less liable to disagree with the stomach than the carrot; it ought, how- ever, to be well boiled, and the watery part sepa- rated by pressure. Lord Townshend, secretary to Charles I., was the person who introduced its use into England; but it appears that the ancient Romans, in the best period of their republic, lived much upon this root. The parsnip is nutritive and digestible, although many persons dislike it on account of its sweet flavour. The Jerusalem artichoke is agreeable, but watery and flatulent; it ought, therefore, never to be eaten without a proper accompaniment of salt and pepper. All the varieties of radishes have a pungent and acrid taste, in consequence of a peculiar stimulating matter, which resides in the cortical part of the root. They may be said to contain little else than water, woody fibre, and acrid matter, and cannot, therefore, be very nutritive; they may act as a stimulant, and thus prove useful, but they ought never to be eaten when old, as the quantity of inert matter in such a condition is apt to disagree with the stomach. From the consideration of radishes, we pass, by an easy transition, to that of onions, &c, for they appear to form the connect- ing link between alimentary roots and those used principally as condiment. The onion, however, although classed under this latter division, and must be considered as valuable on account of its stimulating matter, certainly contains a considera- ble proportion of nourishment. This appears evident in its boiled state, by which process its acrimony is exhaled, and a sweet mucilage sepa- rated. Sir John Sinclair says that it is a well- known fact that a Highlander, with a few raw onions in his pocket, and a crust of bread, or some oat-cake, can travel almost to an incredible extent, for two or three days together, without any other sort of food. The French are fully aware of the quantity of nourishment this plan affords ; hence the soup d I'oignon is considered by them as the best of all restoratives. As a stimulant to the stomach and bowels, the onion, in a raw state, is certainly of value, and this is much enhanced by its diuretic qualities. The leek, garlick, shallot, are of the same species, and possess qualities of the same nature. Horse-radish is a warm and pungent root, and is highly valuable to the dys- peptic as a stimulant; it is, perhaps, the best of all condiments for the prevention of flatulence. Esculent Herbs*—In this class are arranged the leaves and stalks of such vegetables as are eaten at table in the form of " greens and salads." Herbs eaten in a raw state are far less digestible than when cooked. During the heats of summer they are refreshing, and are well calculated to as- suage that febrile state which full meals of ani- mal food are known to occasion. Of all these herbs the water-cress is the most beneficial; for, by operating in some degree as an aromatic, it promotes digestion, and corrects that tendency to flatulency which other raw vegetables are apt to produce. According to Xenophon, the ancient Persians lived upon water-cresses, which they considered the most wholesome of vegetable pro- ductions. The lettuce is generally eaten with other herbs, in the form of a salad, dressed with oil and vinegar. Some difference of opinion has arisen with respect to the propriety of such addi- tions. Gosse, of Geneva, found that vinegar re- tarded its solution in the stomach, and oil has been stated by others to render it less digestible. We have generally found such condiments useful, and that dressed lettuce is less likely to ferment in the stomach than that which is eaten without them. Oil is known to have such an effect in checking fermentation, and the vinegar is not found to pro- mote it. The lettuce contains a narcotic* princi- ple ; and the effect of this is, in a great measure, obviated by a vegetable acid : those persons, there- fore, who eat lettuce with a view to obtain such effects, ought to take it without vinegar. The digestibility of celery is greatly increased by ma- ceration in vinegar. Cucumbers are by far the most unwholesome of all raw vegetables, and should be avoided as poison by dyspeptics. The vegetables which require to be boiled are the different species and varieties of colewort; the value of which does not depend so much upon their nutritive quality as the tenderness of their texture. On this account, the cauliflower and brocoli are the species to be preferred, particularly the younger sprigs of the former. Of the kinds where the leaves only are employed, the Savoy is of a sweeter and more tender texture than the others, particularly its central and upper leaves. The cabbage tribe appear to contain a peculiar essential oil, whence the unpleasant odour of cab- bage-water ; this matter is liable to produce offen- sive effects on the stomach : the vegetable should therefore be boiled in two successive waters, in order to free it entirely from the noxious ingre-' dient, and at the same time to render its texture, soft and digestible. Asparagus is quickly dis- solved in the stomach, and, when sufficiently boil- ed, is not disposed to create flatulence or acidity : along with its mucilage it frequently contains some sweetness, which affords a proof of its nu- tritive quality. From the peculiar odour which it imparts to the urine of those who eat it, it ap- pears to possess some active matter distinct from its mucilage ; and it is generally considered diu- ; retic. Asparagus is only wholesome when in an j intermediate state between root and plant. When older than this, it is remarkably acrid. Fruits.—These are generally regarded as ar- ticles rather of luxury than of food ; and were we to form our opinion of their value from their abuse, we should certainly be rather disposed to class them under the head of poisons than of ali- ments. Nothing can be more mischievous to the invalid than large quantities of apples, pears, and plums, in the form of dessert, after the stomach has been already loaded. But, when taken under other circumstances, they contribute to health, and appear to be providentially sent at a season when the body requires that cooling and antiseptic ali- ment which they are so well calculated to afford. Fruits may be arranged under the following heads : stone fruits, the apple species, small-seed- ed fruits, small berries, and farinaceous fruits. * We are told that Galen in the decline of life, suffer. ed much from morbid vigilance, until he had recourse to eating a lettuce every evening, which cured him. 660 DIETETICS. The stone fruits have been denounced as the least digestible species by popular acclamation, but much of the mischief that has been attributed to their use has arisen from the unripe state in which they were eaten. They are, however, cer- tainly less digestible than other species, and more liable to undergo fermentation in the stomach. The hard pulp of certain plums remains also in the alimentary canal for a long time, and is fre- quently passed without having been materially changed. The ripe peach is the most delicious, as well as one of the most digestible of the stone fruits; the apricot is equally wholesome, but the nectarine is liable to disagree with some stomachs. Cherries are far less digestible; their pulpy tex- ture and skins are not easily disposed of by the stomach ; and as the sweetest species contain a considerable excess of acid, they may be objec- tionable in some cases, and desirable in others. The apple species are not so dilute and watery as the foregoing fruits, and is less apt to pass into a state of noxious fermentation; but its texture is firmer, and on that account it is retained longer in the stomach, and often proves indigestible. The same observations apply to pears, except that, their texture being in general less firm, they are less objectionable. The orange, when perfectly ripe, may be allowed to the most fastidious dys- peptic ; but the white, or inner skin should be scrupulously rejected, for it is not more digestible than leather. The small-seeded fruits are by far the most wholesome. Of these the ripe straw- berry and raspberry deserve the first rank. The grape is also cooling and antiseptic, but the husks and seeds should be rejected. The gooseberry is less wholesome on account of the indigestibility of the skin, which is too frequently swallowed. The fruits to be classed under the head of small berries are the cranberry, the bilberry, and the red whortleberry. These are rarely eaten, except when baked, and in that state their acescency sel- dom proves injurious. The farinaceous fruits are universally unwholesome. The melon, which is the principal one, is very apt to disagree with weak stomachs, and should never be eaten after dinner, even by persons in health, without a plen- tiful supply of salt and pepper. By cookery, fruit, otherwise unwholesome, may be converted into a safe and useful aliment. Ap- ples, when baked, afford a pleasant repast, and from their laxative properties, are well adapted to certain forms of dyspepsia. Dried fruits, from the quantity of sugar which generally enters into their composition, are very much disposed to fer- ment and occasion heartburn. [The following table exhibits the time required for the stomachal digestion of different alimentary substances, in a well-known case, which fell under the care of Dr. Beaumont, and which the writer had an opportunity of seeing. The table is co- pied from another work, (the writer's Elements of Hygiene, 2d edit. Philad. 1844.) The most digestible substances are taken as the standard, which has been arbitrarily fixed at 1000 ; and ac- cordingly, as aponeurosis, the first article in the table, required three hours, whilst pigs'feet soused, rice, &c. required but one, its digestibility compared with that of these aliments, is as 333 to 1000 ; and so of the others. It need scarcely be said, that all such tabular results apply in strictness to the individual concerned only; yet they afford useful comparative views, which, with exceptions depending upon individual peculiarities, may be regarded as approximations applicable to mankind in general. ALIMENTS. Aponeurosis.......... Apples, mellow....... Do. sour, hard..... Do. sweet, mellow . . Barley.............. Bass, striped, fresh Beans, pod........... Do. and green corn . . Beef, fresh, lean, rare.. . Do. do. do. dry ... do. steak...... with salt only with mustard, &c. Do. Do. Do. Do................ Do. old, hard salted.. . Beets............... Brains, animal........ Bread, corn.......... Do. wheat, fresh .... Butterj-.............. Cabbage, head........ Do. with vinegar.. Do.............. Cake, corn........... Do. sponge......... Carrot, orange........ Cartilage............ Catfish, fresh......... Cheese, old, strong..... Chicken, full grown. . .. Codfish, cured dry..... Corn, (green) and beans Custard ............. Duck, domesticated .... Do. wild........... Dumpling, apple...... Eggs, fresh........... Do. do............ Do. do............ Do. do............ Do. do............ Do. do............ Flounder, fresh....... Fowls, domestic....... Do. do........ Gelatin.............. Goose, wild.......... Heart, animal......... Lamb, fresh.......... Tim« |requird for "Mo- nachal dutrti. lion. boiled raw do. do. boiled broiled boiled do. roasted do. broiled boiled do. fried boiled do. do. baked baked melted raw do. boiled baked do. boiled do. fried raw fricasseed boiled do. baked roasted do. boiled hard boiled soft boiled fried roasted raw whipped fried boiled roasted boiled roasted fried boiled h. m. 3 2 2 50 1 50 2 3 2 30 3 45 3 3 3 2 3 4 4 15 30 «et'- Umpir- ed «ith Ihe nicut digesti- ble arti- cle-* in Ihelible 3 45 1 45 3 15 3 30 3 30 2 30 2 4 30 * [Pigs' feet soused, rice, and tripe soused.being the most digestible articles in the table, are estimated at t [In the case of oils, and other substances of similar nature, which undergo little digestion in the stomach, the time merely indicates the period that elapses before they are sent into the duodenum j DIETETICS. 661 ALIMENTS. Liver, beef's, fresh..... Marrow, animal, spinal . Meat and vegetables. . .. Milk................ Do................. Mutton, fresh......... Do. do.......... Do. do.......... Oysters, fresh......... Do. do.......... Do. do.......... Parsnips............. Pig, sucking.......... Pigs' feet, soused...... Pork, fat and lean...... Do. recently salted.... Do. do....... Do. do....... Do. do....... Do. do....... Potatoes, Irish........ Do. do......... Do. do......... Rice................ Sago................ Salmon, salted........ Sausage, fresh........ Soup, barley.......... Do. bean........... Do. beef, vegetables, & bread......... Do. chicken........ marrow bones.... mutton......... Do. Do. Do. oyster.......... Suet, beef, fresh....... Do. mutton......... Tapioca............. Tendon, boiled........ 'I ripe, soused......... Trout, salmon, fresh. . .. Do. do......... Turkey, domestic...... Do. do....... Do. wild......... Turnips, flat......... Veal, fresh........... Do. do............ Vegetables and meat, hashed .......... Venison, steak........ Time Form of prepa-ration. niachal llOn. boiled A. m. 2 do. 2 40 hashed 2 30 boiled 2 raw 2 15 roasted 3 15 broiled 3 boiled 3 raw 2 55 roasted 3 15 stewed 3 30 boiled 2 30 roasted 2 30 boiled 1 roasted 5 15 boiled 4 30 fried 4 15 broiled 3 15 raw 3 stewed 3 boiled 3 30 roasted 2 30 baked 3 20 boiled 1 do. 1 45 do. 4 broiled 3 20 boiled 1 30 do. 3 do. 4 do. 3 do. 4 15 do. 3 30 do. do. do. do. do. boiled do. fried roasted boiled roasted boiled broiled fried warmed broiled I Ratio of di.^o.i - bility compar- ed «i h 3 5 4 2 5 1 1 1 2 2 25 2 18 3 30 4 4 30 2 30 1 35 30 301 30 500 375 400 500 444 3u7 333 333 342 307 285 400 400 1000 190 222 235 302 333 333 285 400 400 1000 571 250 300 666 333 250 333 235 285 285 181 222 500 181 1000 666 666 400 511 435 285 250 222 400 631] Of Drinks, oh Liquid Aliments.—As the introduction of solid aliment into the stomach is for the purpose of furnishing materials for the re- pair of the different textures, so is a supply of liquid matter essentially necessary to replace the fluids which are constantly ejected from the body, during the exercise of ite numerous functions. In this point of view, therefore, the drinks ought to be considered as real aliments. The chyme and 3r the chyle may also require the assistance of some liquid medium to increase the fluidity of the mass, or to favour the absorption of its finer and more nutritive parts In every point of view, therefore, dilution is an essential operation ; and an animal will not only endure the sensation of hunger with more tranquillity than that of thirst, but he will survive longer under the privation of solid than of liquid aliment. Before we enter upon this part of the suhje-t, it will be necessary that we should offer a few re- marks upon the nature of the changes which liquids undergo when introduced into the stomach, and which would appear to be determined by the nature of their composition. The subject teems with curious facts, and is one of much importance to the physician, as it will enable him to appre- ciate the utility of liquid diet, and to understand the circumstances which should decide its prefer- ence. It was long supposed that liquids, like solids, passed through the pylorus into the intestines, and were absorbed together with the chyle, or rejected with the excrement. It is not asserted that this never occurs; but it is evident beyond contradic- tion that there must exist another passage, although its nature remains obscure, by which liquids can be conveyed to the circulation ; for it has been shown that, if a ligature be applied round the py- loric orifice, in such a manner as to obliterate the passage into the duodenum, the disappearance of the liquid from the cavity of the stomach is not so much even as retarded. In order to discover whether drinks are absorbed along with the chyle, M. Magendie made a dog swallow a certain quan- tity of diluted spirit during the digestion of his food; in half an hour afterwards the chyle was extracted and examined : it exhibited no trace of spirit, but the blood exhaled a strong odour of it, and by distillation yielded a sensible quantity. If a liquid, holding nutritive matter in solution, be introduced into the stomach, it is either coagu- lated by the gastric juice, or its watery part is absorbed, and the solid matter deposited in the stomach; in either case the solid product is con- verted into chyme. Milk, as we formerly observed, appears to be the only liquid aliment which Na- ture has prepared for our nourishment; but it seems that she has, at the same time, provided an agent for rendering a certain portion of it solid, and hence we are led to infer that this form is an indispensable condition of bodies which are des- tined to undergo the processes of chymification and chylification; and that, unless some provision | had existed for the removal of fluids from the stomach, the digestive functions could not have been properly performed. When the broth of meat is introduced into the stomach, the watery part is carried off, and the gelatine, albumen, and fat are then converted into chyme. Wine and fermented liquors undergo a similar change ; the alcohol which they contain coagulates a portion of the gastric juice, and this residue, together with the extractive matter, gum, resin, and other prin- ciples which the liquid may contain, is then digested. Under certain circumstances these liquids may observe a different law of decomposi- tion, which will, perhaps, in some measure explain the different effects which such potations will «82 DIETETICS. produce; for example, the spirit may undergo a partial change in the stomach, and be even digest- ed with the solid matter, or, on some occasions, be converted into an acid by a fermentative pro- cess ; this will be more likely to occur in vinous liquors, which contain ingredients favourable to the production of such a change, and hence the deleterious property of fermented liquors does not bear an unvarying relation to the absolute quan- tity of their alcohol. Oil, though possessing the fluid form, does not appear to observe the law which governs the disposal of such bodies; it is not absorbed, but is entirely transformed into chyme by the stomach. To effect this change, however, it seems essential that the stomach should be in a state of high energy, or the fluid will undergo chemical decomposition; nor will the stomach, unless it be educated, as it were, to this duty, like those of some northern nations, digest any considerable quantity of it; and since it cannot be absorbed, it must find its exit through the alimentary canal, and consequently prove laxative. In classing the different species of drinks, we may, as with solids, arrange them according to their chemical composition, thus— I. Water.—Spring, river, well-water, &c. II. The juices and infusions of asimai and vegetable substances.— Whey, tea, coffee, &c III. Fermented ltq.uors.— Wine, beer, &c IV. The alcoholic liq_loks, or spirits.— Alcohol, brandy, rum, &c. Water. — The qualities of water differ essen- tially according to the source from which it has been obtained ; and those accustomed to this beverage are sensible to differences which wholly escape the observation of less experienced judges. How far the existence of foreign matter injures its salubrity has been a subject of much contro- versy. That the presence of very minute quantities of earthy matter can become a source of disease sounds strangely to the ears of the philosopher; and yet we have known patients, after drinking a glass of water, from a sense of weight and oppres- sion at the stomach, at once pronounce the exist- ence of foreign ingredients. Animals would appear to be generally mors sensible of such impurities than man. Horses, by an instinctive sagacity, always prefer soft* water ; aud when, by necessity or inattention, they are confined to the use of that which is hard, their coats become rough and ill- conditioned, and they are frequently attacked with gripes. Pigeons ate also known to refuse hard, after they have been accustomed to soft water. We are informed by Cleghorn that on the eastern side of the island of Minorca, the sheep, on ac- * An important practical distinction has been founded upon the fact, that the water of some sprinrs will ilis- Bolve soap, while that of others di-roinposes and curdles it; the former has been denominated soft, the latter hard water. Sulphate of lime is generally the salt which im- parts this quality of hardness; and it appears that the proportion of live grains to tiie pint is sufficient for the purpose Soli water is a more powerful solvent of all vegetable matters, and is consequently to be preferred for domestic as well as medicinal use. The brewer knows well, from experience, how much more readily ami copiously soft water will dissolve the extractive matter of his malt; and the housewife requires not the chemist to inform her that hard water is incapable of making good lea. | count of the hardness of the water, are subject to i a disease in the spleen. But the most dangerous sources of impurity exist in the animal and vege- i table kingdoms; putrescent matter poisons our beverage, and becomes the secret cause of numer- 1 ous complaints. The usual varieties of common ' water were classed and defined by Celsus, and ' modern chemists have not found any reason to reject the arrangement. " Aqua levissima plu- vialis est,- dein fontana, turn ex fiumine, turn ex puteo ,- post hxe ex nive out glacie, gravior his ex lacu, gravissima ex palnde." We may remark of river water, that, as it is derived from the conflux of numerous springs and rain water, the proportion of its saline constituents ought to be small, since various precipitations must necessarily take place from the union of different solutions. It is, however, liable to hold in suspension particles of earthy matter which impair its transparency, and not unfrequently its salubrity. It may also, in the vicinity of a large town, hold dissolved, as well as suspended, a con- siderable portion of animal and vegetable matter: this is unquestionably the case in the water sup- plied from the Thames by the Grand Junction Water-Company. For the purification and preservation of water, numerous ingenious methods have been adopted. The mechanical impurities may be easily enough removed by filtration, a process which is suggested by Nature herself, for all springs arising through sand, gravel, dec. must undergo such an operation; but it will not remove a particle of that matter which is held in solution, and hence the filter is only of partial utility. As that peculiar property which constitutes what is termed hardness gener- ally depends upon sulphate of lime in solution, it cannot be removed by filtration, but the addition of an alkaline carbonate, in the proportion of from ten to fifteen grains, to every pint, twenty-four hours before it is used, will be found to soften it; or, if it should be found to dejrend upon super- carbonate of lime, which is sometimes the case, long ebullition, without any addition, will be found sufficient for its cure. Another mode of improving water, and one which has been lately adopted by Mr. Robins in his patent filters, is by i the application of charcoal, a substance which possesses in an eminent degree the property of preserving water from corruption, and of purifying I it after it has been corrupted; hence the filtration of water through alternate layers of sand' and I charcoal offers the readiest and most effectual I mode of abstracting its impurities with which we are acquainted.f Where we have reason, how- ever, to suspect much injurious contamination, the process of boiling should never be omitted; after which it may be strained and filtered, and lastly agitated in contact with the atmosphere, in order to restore to it its natural proportion of air. In China, water is never drunk until it has been boiled. The mischievous effects of impure water, where it cannot be corrected by any chemical process, are said to be best counteracted by some bitter vegetable. \ irey supposes that this circum- t The great desideratum has ever been to remove soluble matters from water; it is by no means impossible that a simple voltaic apparatus will hereafter be con- trived for such a purpose. DIETE stance first induced the Chinese to infuse the leaves of the tea-plant. Water is unquestionably the natural beverage of man; but any objection against the use of other fluids founded on their artificial origin, may be at once met by the same argument which has been adduced in defence of cookery. We are to consider man as he is, not as he might have been had he never forsaken the rude path of nature. We are ready to admit that the more simply life is supported, and the less stimulants we use, the better; and that he is happy who considers water the best drink, and salt the best sauce; but how rarely does a physician find that his patient has regulated his life by such a maxim ! He is gene- rally called upon to reform stomachs already vitiated by bad habits, and which cannot, without much discipline, be reconciled to simple and wholesome aliment. Under such circumstances, nothing can be more injudicious than abruptly to withdraw the accustomed stimulants, unless it can be clearly shown that they are absolutely injuri- ous,—a question which it will be our duty to in- vestigate. The juices and infusions of vegetable and ani- mal matter constitute the second division of drinks. Toast-Water.—By impregnating water with the soluble parts of toasted bread, we shall obtain a liquid which will frequently agree with those stomachs which rebel against the use of the more simple fluid. It is thus also rendered slightly nutritive, holding a certain portion of gum and starch in solution. Sir A. Carlisle recommends that it should be prepared with hard biscuit, re- duced by fire to a coffee colour. " This drink," says he, " being free from yeast, is a most agree- able beverage. Much depends upon the water, employed for its preparation, being at a boiling temperature, and it ought to be drunk as soon as it has sufficiently cooled; for, by being kept, it acquires a mawkish and unpleasant flavour. In- fusions of other kinds of bread, especially those of toasted oat-cakes, and dried or toasted oatmeal, have been recommended; but the taste of such infusions would not be palatable to any one who has not been accustomed to oat-bread. Barley-Water.—The decoction of barley is a very ancient beverage; it is recommended by Hippocrates, and preferred by him to every other aliment in acute diseases. Barley has the ad- vantage over other grains, in affording less viscid potations. The invention of pearl barley has greatly increased the value of this grain; it is prepared by the removal of its husk or cuticle, and afterwards by being rounded and polished in a mill. These well-known granules consist chiefly of fecula, with portions of mucilajze, gluten, and sugar, which water extracts by decoction ; but the solution soon passes into the acetous fer- mentation. The bran of barley contains an acrid resin, and it is to get rid of such an ingredient that it is deprived of its cuticle. The addition of lemon-juice and sugar-candy greatly improves the flavour of this drink. Gruel.—Oats, when freed from their cuticle, are called groats; in which state, as well as when ground into meal, they yield to water, by coction, the fecula they contain, and form a nutritious TICS. 663 gruel, which has also the property of being slightly aperient, It should never be kept longer than forty-eight hours, as it becomes acescent after that period. Gruel may be made of a different degree of consistence, according to the object of its pota- tion. If it be used as a demulcent drink, it should be thin ; and may be made, as Dr. Kitchener, our culinary censor, informs us, by mixing well together, by degrees, in a pint basin, one table- spoonful of oatmeal with three of cold water, and then adding carefully a pint of boiling water, which is to be boiled for five minutes, stirring it all the time, to prevent the oatmeal from burning at the bottom of the stewpan ; then strain through a hair sieve, to separate the undissolved parts of the meal from the gruel. If a more substantial repast is required, double the above quantity of oatmeal must be treated in a similar manner. To increase the nutritive quality of this aliment, broth or milk may be substituted for water. Some per- sons are in the habit of introducing a piece of butter into gruel; but the propriety of this prac- tice is questionable, where the stomach is sup- posed to generate acidity. Sage Tea.—The virtues of sage have been so extravagantly praised, that, like many of our re- medies, the plant is fallen into disuse from the disgust which its panegyrists have excited. We are convinced, however, that in the form of in- fusion it possesses some power in allaying the irritability of the stomach, (it is frequently used by the Chinese as a tonic for debility of the sto- mach,) and that, on many occasions, it will furnish a salutary beverage. The same observa- tion will apply to the infusions of balm and rose mary. A drink extremely agreeable to the sto mach of invalids may also be made by infusing lemon-peel in boiling water, and adding a small quantity of sugar. Tea.—There is no subject that has occasioned a greater controversy amongst dietetic writers than that of tea. By one party it is decried as a poi- son ; by another it is extolled as a medicine, ani a valuable addition to our food ; while some refej all ite beneficial effects to the water thus intro- duced into the system, and its evil consequences to the high temperature at which it is drunk, (ti order to understand the value of the different ar- guments which have been adduced in suppjrt or to the disparagement, of this beverage, it /III be necessary to inquire into its composition. Two kinds of tea are imported into this country, dis- tinguished by the epithets black and green Both contain astringent and narcotic principles, but in very different proportions; the latter producing by far the most powerful influence upon the ner- vous system. As the primary operation of evory narcotic stimulant, tea is found to exhil irate and refresh us, although there exist individuals who are so morbidly sensible to the action of certain bodies of this class, thut feelings of depression, accompanied with various nervous sensations and an unnatural vigilance, follow the potation of a single cup of strong tea ; while others experience, from the same cause, symptoms indicative of derangement of the digestive organs: but these are exceptions* from which no general rule ought * The reader is r« ferred ton pamphlet entitled " Ob- servations on the Medicinal and Dietetic Properties of 664 DIET to be deduced. The salubrity of the infusion to the general mass of the community is established by sufficient testimony to outweigh any argument founded on individual cases. It must, however, be admitted, that if this beverage be taken too soon after dinner, the digestion of the meal may be disturbed by the distension it will occasion, as well as by its influence as a diluent; the narcotic and astringent principles may also operate in arresting chymification; but when a physician gives it his sanction, it is with the understanding that it shall be taken in moderate quantities, and at appointed seasons. In enumerating the ad- vantages of tea, it must not be forgotten that it has introduced and cherished a spirit of sobriety ; and it must have been remarked by every phy- sician of general practice, that those persons who dislike tea, frequently supply its place by spirit and water. The addition of milk certainly di- minishes the astringency of tea; that of sugar may please the palate, but cannot modify the vir- tues of the infusion. Coffee. — The hostility which has been mani- fested against the use of tea has been extended, with equal rancour, against that of coffee, and, probably, with equal injustice. The principle upon which its qualities depend is more stimulant than that of tea, and certainly exerts a different species of action upon the nervous system, al- though it is very difficult to define the nature of this difference. If taken immediately after a meal, it is not found to create that disturbance in its digestion which has been noticed as the occasional consequence of tea; on the contrary, it accelerates the. operations of the stomach, and will frequently enable the dyspeptic to digest substances, such as fat and oily aliment, which would otherwise oc- casion much disturbance. The custom of taking coffee immediately after dinner, so universally practised by the French, no doubt must counteract the evil effects which the peculiar form of their diet is calculated to produce. Coffee, like tea, has certainly an antisoporific effect on many indi- viduals ; it imparts an activity to the mind which is incompatible with sleep ; but this will rarely occur if the beverage be taken for several hours before our accustomed period of repose. It seems to be generally admitted that it possesses the power of counteracting the effects of narcotics; and hence it is used by the Turks with much ad- vantage, in abating the influence of the inordinate quantities of opium they are accustomed to swal- low. When our object is to administer it as a promoter of digestion, it should be carefully made by infusion; decoction dissipates its aroma. The addition of milk is one of questionable propriety ; that of sugar, or rather sugar-candy, may be al- lowed. Some persons can never take this be- verage without suffering from acidity in the stomach: where this happens, the practice must be abandoned. Green Tea," by W. Newnham, Esq. There is a great deal of sound sense in this little production. The author refers the different effects produced by green tea to the different states of the system in which it is taken. He maintains, that in a state of what he calls sthenic excite- ment of the brain and nervous system, as that produced by alcoholic stimulants, or by intense and long-con- tinued application of the mind to any particular object of literary search, preen tea will act as a salutary re- medy ; whereas, on the contrary, in states of diminished excitement, morbid vigilance and nervous disturbance will follow its potation. TICS. [It appears from recent investigations of organic chemists, that Theinc, the peculiar principle of tea, and Caffeine, the principle of coffee, are iden- tical. " We shall never certainly," says Liebig, (Animal Chemistry, edit. cit. p. 169,) «be able to discover how men were led to the use of the hot infusion of the leaves of a certain shrub (tea), or of a decoction of certain roasted seeds (coffee). Some cause there must be, which would explain how the practice has become a ne- cessary of life to whole nations. But it is surely still more remarkable, that the beneficial effects of both plants on the health must be ascribed to one and the same substance, the presence of which in two vegetables, belonging to different natural families, and the produce of different quar- ters of the globe, could hardly have presented itself to the boldest imagination. Yet recent researches have shown, in such a manner as to exclude all doubt, that caffeine, the peculiar principle of cof- fee, and theine, that of tea, are, in all respects, identical." And he adds (p. 170) : "Without entering minutely into the medicinal action of caf- feine (theine), it will surely appear a most striking fact, even if we were to deny its influence on the process of secretion, that this substance, with the addition of oxygen and the elements of water, can yield taurine, the nitrogenized compound peculiar to bile."] Chocolate. — In consequence of the large quantity of nutritive matter which this liquid con- tains, it should be regarded rather as food than drink. It is prepared by reducing the cocoa-nut into paste, with sugar, milk, or eggs : it is also frequently mixed with different aromatics, the most common of which is the vanilla, a substance very liable to disagree with the stomach, and to produce a train of nervous symptoms. As a com- mon beverage, chocolate is highly objectionable; it contains an oil which is difficult of assimila- tion ; it therefore oppresses the stomach: this effect is of course increased by the application of too much heat in its preparation. Another ob- jection against its use is to be found in the obser- vations which we have already offered upon the subject of too great concentration. Cocoa is usually considered as a substitute for chocolate. As it contains less nutritive matter, it is not so objectionable; and, as the oily matter exists only in small quantities, it is less likely to disagree with the stomach. There are certain saline solutions which are fre- quently employed as drinks, and deserve some attention in this place : such are imperial and soda water. Imperial is a solution of cream of tartar flavoured with lemon-peel. It ought never to be used except as a medicine. If employed as an ordinary drink, it is apt to retard digestion. If ever useful as an article of diet, it will be under circumstances of robust health, and where a large quantity of animal food has been taken. The modern custom of drinking soda water during, or immediately after dinner, has been a pregnant source of dyspepsia. By inflating the stomach at such a period, we inevitably counteract those mus- cular contractions which are essential to chymifi- cation. The quantity of soda thus introduced scarcely deserves notice : with the exception of the carbonic acid gas, it may be regarded as water, more mischievous only in consequence of DIETETICS. 665 the exhilarating quality inducing us to take it at a period at which we should not require the more Simple fluid. Fermented Liquors---Volumes have been written to prove that spirit, in every form, is not only unnecessary to those who are "in health, but defect that is necessarily inherent in the wines of this country, and which leads them to partake of the properties of cider; for in the place of the tartaric, the malic acid always predominates in our native fruits. The characteristic ingredient of all wines is ,i , ;. l j ,, ,.„ ----*""t """ | ^ "^ uuuu.u.iuuii inuieuieiu oi an wines la that it has been the prolific source of the most alcohol; and the quantity of this, and the condi- painful and fatal diseases to which man is subject; I '' in short, that Epimetheus himself did not, by I opening the box of Pandora, commit a greater act ' of hostility against our nature than the discoverer ' of fermented liquors. This is a striking specimen I of the fallacy of reasoning against the use of a I custom from ite abuse. There exists no evidence to prove that a temperate use of good wine, when ' taken at seasonable hours, has ever proved inju tion or state of combination in which it exists, are the circumstances that include the more interest- ing points of inquiry, and explain the relative effects which different wines produce upon the system ; we shall therefore proceed to investigate the various species, with reference to such condi- tions. Wines may be at once resolved into two great divisions; into those which are coloured, and rious to healthy adults. In youth, and still more j commonly called red wines, and into those which in infancy, the stimulus wliich it imparts to the stomach is undoubtedly injurious ; but there are exceptions even to this general rule. The occa- sional use of diluted wine has improved the health of a child, by imparting vigour to a torpid stomach : we ought, however, to consider it rather as a me- dicine than as a luxury. Without entering further into the discussion of a question which has called so many opponents into the field, it may be observed that whatever opinion we may have formed as to the evils or advantages consequent upon the invention of wine, we are not called upon, as physicians, to defend it; our object is to direct remedies for the cure of those diseases which assail man as we find him in the habits of society. And as these habits, says Dr. W. Philip, are such that more or less alcohol is necessary to support the usual vigour of the greater number of people even in health, nothing could be more injudicious than wholly to deprive them of it when they are already weak- ened by disease, unless it could be shown that even a moderate use of it essentially adds to their disease, which, in dyspeptics, is by no means the case. Our own experience coincides with that opinion. In cases where the vinous stimulant has been withdrawn, we have generally witnessed an aggravation of the dyspeptic symptoms, accompa- nied with severe depression of spirits. The term wine is more strictly and especially applied to express the fermented juice of the grape; although in common language it is used to denote that of any sub-acid fruit. The presence of tartar is perhaps the circumstance by which the grape is more strongly distinguished from all the other sub-acid fruits that have been applied to the art of wine-making. Its juice, besides, con- tains within itself all the principles essential to vinification, in such a proportion and state of balance as to enable it at once to undergo a regu- lar and complete fermentation ; whereas, the juices of other fruits require artificial additions for this purpose: and the scientific application and due adjustment of these means constitute the art of making domestic wines.* It has been remarked that all those wines which contain an excess of malic acid are of a bad quality : hence the grand * For an account of which, the reader is referred to a most ingenious and interesting essay by Dr. Macculloch, entitled " Remarks on the Art of making Wine; with Suggestions for the Application of its Principles to the Improvement of Domestic Wines." Vol. I___84 3r» have a yellow tinire, more or less deep, termed white wines. This colouring matter is not de- rived from the juice, but from the husk of the grapes. If, therefore, the fermentation be not per- mitted to take place in contact with the hulls, and sometimes even with the stalks of the fruit, a white wine is in all cases produced. This colour- ing matter is highly astringent, and consequently the red wines differ from the white in their effects upon the stomach; and yet it is difficult to ex- plain the well-known extent of this operation by the presence of so small a proportion of active matter. It must, however, be remembered that irritable stomachs are frequently impatient of astringent matter. Many persons are incapable of drinking port wine in consequence of the heart- burn it occasions; while others, on the contrary, appear to derive advantage from the tonic influ- ence of its astringency. This is a circumstance of idiosyncrasy which no theory can explain. Every physician must be practically aware of the caprice which the stomach displays in its morbid conditions ; but as a general rule, it may be stated that ujhite deserve a preference over red wines, because the latter, being pressed, and subjected to a stronger fermentation to extract the colouring principle from the husk, are necessarily more loaded with extractive and astringent matter ; and as this retnains in the stomach after the liquid portion of the wine is absorbed, it will be liable to occasion disturbance. The odour, or bouquet, and flavour which dis- tinguish one wine from another, evidently depend upon some volatile and fugacious principle not hitherto investigated by the chemist: this, in sweet and half-fermented wines, is immediately derived from the fruit, as in those from the Frontignan and Muscat grapes; but in the more perfect wines, as in Claret, Hermitage, Rivesaltes, and Burgundy, it bears no resemblance to the natural flavour of the fruit, but is altogether the product of the vinous process. Some wines are artificially flavoured by the introduction of foreign ingre- dients, as by almonds in Madeira wines, as well as in those of Xeres and St. Lucar; and hence their well-known nutty flavour. Among the an- cients, and in modern Greece, it is at this day the fashion to give a resinous flavour, by the intro- duction of turpentine into the casks. These wines were supposed to assist digestion, to restrain mor- bid discharges, to promote urine, and to strengthen the bowels; but Dioscorides informs us that they DIETETICS. were known to produce vertigo, pain in the head, and many evils not incidental to the potations of Ihe same vinous liquor when free from such ad- mixtures. The quantity of acid contained in wines has been supposed capable of diminishing their salu- brity, and in some cases of rendering them emi- nently noxious. There can be no doubt that where there exists a considerable excess of gallic or malic acids, or where acetic acid has been gene- rated during a protracted fermentation, such wine will be obnoxious to the stomach; but where the acid arises from the nature of the fruit, it surely cannot merit the odium which popular opinion would assign to it. What, for instance, is the acid contained in Madeira, and against which so many objections have been urged ? an atom merely •f tartar ! And yet the person who fancies that his digestion can be deranged by its action, will swallow twenty times the quantity of the same ingredient in some other shape with perfect indif- ference and impunity. Before we quit the subject of vinous acidity, we must add a few words upon its supposed influ- ence in exciting paroxysms of gout. That such attacks have followed particular potations we do not mean to deny; but a slight excess of any kind, whether in diet or in exercise, will excite the disease in those predisposed to it. Where this predisposition exists, an additional glass of claret may excite the disease ; but in all such cases any other exciting cause would have a similar effect. It has been already stated that the characteristic ingredient of all wines is alcohol; and that its quantity, and the condition or state of combination in which it exists, are the circumstances in which the medical inquirer is principally interested. The late experiments of Mr. Brande have thrown considerable light upon this subject; although, as in most instances of discovery, they have raised up new doubts and difficulties. Daily experience convinces us that the same quantity of alcohol applied to the stomach under the form of wine, and in a state of mixture with water, will produce very different effects upon the body, and to an extent which it is difficult to understand. It has, for instance, been demonstrated beyond the reach of doubt, that port, madeira, and sherry contain from one-fourth to one-fifth of their bulk of alco- hol ; so that a person who takes a bottle of any one of them will thus take nearly half a pint of alcohol, or almost a pint of pure brandy ! And, moreover, that different wines, although containing the same absolute proportion of spirit, will be found to vary very considerably in their intoxi- cating powers. No wonder, then, that such results should have staggered the philosopher, who is naturully unwilling to accept any teste of dif- ference from the nervous system, which elude the ordinary resources of analytical chemistry. The conclusion was therefore drawn, that alcohol must necessarily exist in wine in a far different condi- tion from that in which we know it in a separate state; or, in other words, that its elements only could exist in the vinous liquor, and that their union was determined, and, consequently, alcohol produced, by the act of distillation. That it was ihe product, and not the educi of distillation, was an opinion which originated with Rouelle, who asserted that alcohol was not completely formed until the temperature was raised to the point of distillation. More lately, the same doctrine was revived and promulgated by Fabbroni, in the Memoirs of the Florentine Academy. Gay Lus- sac has, however, silenced the partisans of this theory, by separating the alcohol by distillation, at the temperature of 66° Fahrenheit; and, by the aid of a vacuum, it has since been effected at 56°. And to complete the demonstration, Mr. Brande has shown that, by precipitating the colouring matter, and some other elements of the wine, by the sub-acetate of lead, and then satu- rating the clear liquor with sub-carbonate of potass, the alcohol may be separated without any eleva- tion of temperature; and he has accordingly, by this ingenious expedient, been enabled to construct a table, exhibiting the proportions of spirit which exist in the several kinds of wine. No doubt, therefore, can any longer be entertained upon the subject; and the fact of the difference of effect produced by the same bulk of alcohol, when pre- sented to the stomach in different states, is to be explained on the supposition that, in wine, it is not only more intimately mixed with water, but that it exists in combination with its extractive matter; in consequence of which it is incapable of exerting its full effects before it becomes altered in its properties, or, in other words, partially digested; and this view of the subject may be fairly urged in explanation of the fact, that the intoxicating effects of the same wine are liable to vary in degree in the same individual, from the peculiar state of his digestive organs at the time of its potation. We have hitherto only considered alcohol as it exists in a combined state in wine ; but it is essential to state that the stronger wines of Spain, Portugal, and Sicily, are rendered marketable in this country by the addition of brandy, and must consequently contain more or less uncombined spirit; but the proportion of which will not bear a ratio to the quantity added, because, at the period of its admixture, a renewed fermentation is produced by the scientific vintner, which will assi- milate and combine a certain portion of the foreign spirit with the wine : this manipulation, in tech- nical language, is called "fretting in." It is to the quantity of free, not to that of combined spirit, that the injurious effects of such wines are to be attributed. " It is well known," observes Dr. Macculloch, " that diseases of the liver are the most common and the most formidable of those produced by the use of ardent spirits." It is equally certain that no such disorders follow the intemperate use of pure wine, however long indulged in : to the concealed and unwitting con- sumption of spirit, therefore, as contained in the wines generally drunk in this country, is to be attributed the excessive prevalence of those hepa- tic affections, which are comparatively little known to our continental neighbours. Much has been said about the effects of new wine upon the stomach, compared with those pro- duced by that which has been long kept. It will be necessary to consider the changes produced in this liquor by being kept. In the first place, red wine gradually deposits a quantity -of cream of tartar, in combination with extractive and colour- DIETETICS. 667 mg matter, forming what is commonly called the crust; so that* considerable portion of that mat- ter which is likely to disagree with the stomach is thus removed , but when kept in a cask, in ad- dition to this change, a quantity of water is evapo- rated, and the wine becomes comparatively strong- er. The custom of exposing Madeira to motion, and a certain elevation of temperature, by send- ing it a voyage to the East Indies, unquestionably improves the flavour, and produces some internal change in the composition of the wine, which the chemist is unable to explain. In a dietetic point of view, wines may be ar- ranged into four classes ; viz. 1, sweet wines,- 2. sparkling or effervescing,• 3. dry and light; 4. dry and strong. 1. Sweet wines contain the greatest proportion of extractive and saccharine matter, and generally the least ardent spirit, though it is often rather disguised than absent. Since a proportion of su- gar has remained unchanged in these wines dur- ing the process of vinification, they must be con- sidered 9s the results of an imperfect fermentation, and are, in fact, mixtures of wine and sugar; ac- cordingly, whatever arrests the progress of fer- mentation must have a tendency to produce a sweet wine. Thus, boiling the must, or drying the fruit, will, by partially separating the natural leaven, and dissipating the water, occasion such a result as is exemplified by the manufacture of the wines of Cyprus, the Vino Cotto of the Ital- ians, and the Vinum Coctum of the ancients ; by that of Frontignac, the rich and luscious wines of Canary, the celebrated Tideay, Vino Tinto (Tent of Hungary), the Italian Montefiascone, the Persian Schiraz, the Malmsey wines of Can- dia, Chio, Lesbos, and Tenedos, and those of the other islands of the Archipelago. On account of the sugar contained in such wines, they are liable to become acescent on weak stomachs ; but where this is not the case, they are, in small quantities, frequently beneficial to invalids. 2. Sparkling or effervescing wines. — These are indebted for their characteristic properties to the presence of carbonic acid ; they rapidly intox- icate, in consequence of the alcohol which is sus- pended in, or more probably, in chemical combi- nation with the gas, being thus applied in a sud- den and very divided state to a large extent of nervous surface : for the same reason their effects are generally as transitory as they are sudden. Independently of the alcohol thus held in solu- tion in the carbonic acid, it is probable that some active aromatic matter is volatilised together with it, and which may account for the peculiar effects produced on some persons by champagne. 3. Dry and light wines—These are exempli- fied by the more esteemed German wines, as hock, rhenish, mayne, moselle, neckar, and elsass; and those highly-flavoured wines, burgundy, claret, hermitage, &c. The former of these wines com- bine the effect of an acid with that of the spirit. They do not contain any uncombined alcohol, and on that account are to be greatly preferred. Genuine claret must be considered as the most beneficial of all our vinous liquors ; it is well fer- mented ; and pn account of the small proportion of spirit, as well as of extractive, which it con- tains, it is more salubrious than port. It has been already observed that burgundy appears to hold dissolved some unknown principle of great activ- ity ; upon no other supposition can we explain its stimulant properties. A few glasses of this wine will produce heat and headach, which the relative quantity of alcohol in its composition will not account for. 4. Dry and strong wines, as madeira, port, sherry, &c. The name sec, corruptly written sack, signifies dry. The sec wine, prepared at Xeres, in Spain, is called, according to our ortho- graphy, sherris or sherry. In the manufacture of this wine, lime is added to the grapes; a cir- cumstance, observes Dr. Macculloch, apparently conducive to its well-known dry quality, and which, probably, acts by neutralizing a portion of malic or tartaric acid. It is a fact not easily explained, that the sto- mach is frequently outraged by a wine to which it has not been accustomed ; and it is equally true that a mixture of different wines is a common source of indigestion. The custom of mixing wine with water has its advantages as well as its evils. By dilution it frequently proves too little stimulant to the stomach, and runs into a state of acescency. An invalid is also thus liable to deceive himself, by taking more wine than may be consistent with his welfare. Much, however, depends upon the quality of the wine taken; the lighter wines cannot require dilution, while port is certainly rendered less injurious by the admix- ture. Home-made or domestic wines may be gene- rally considered as injurious to delicate stomachs; they are apt to ferment and produce indigestion. Cider and perry are grateful drinks in hot wea- ther ; but as they do not contain a sufficient quan- tity of spirit to prevent their passing into the ace- tous fermentation in the stomach of an invalid, they should be avoided by those who have any predisposition to indigestion. Beer.—This is an article of beverage in almost every country. The Chinese prepare it from rice, and the Americans from maize. We are also in- formed by Herodotus, that, in very early history, the art of making a fermented liquor from barley was discovered by the Egyptians. As the cli- mate of England is not congenial to the growth of the vine, this species of liquor is perhaps more universal than in any other country ; and it has therefore been denominated vinum Britannicum. In the higher walks of society, it has, indeed, of late years, been nearly excluded: but whether this revolution has been attended with advantage, we shall presently have occasion to inquire. Malt liquors differ from wines in several essential points: they contain a much larger proportion of nutritive matter, and a less proportion of spirit; while they contain a peculiar bitter and narcotic principle derived from the hop. It would appear that the extractive matter furnished by the malt is highly nutritive ; and we accordingly find that persons addicted to such potations are in general fat. Where, however, they are indulged in to any ex- tent, without a corresponding degree of exercise, they induce a plethoric state of the body, and all the diseases consequent upon such a condition. In order to understand the process by which they furnish nourishment, we must once more refer 668 DIETETICS. 'the reader to the observations which are offered on the important subject of the digestion of li- quids; from which it will appear that highly-con- centrated extract will be left in the stomach after the removal of its watery part. This extract is, for reasons already stated, not verv digestible ; and will therefore require the presence of ^ess in- spissated food to promote its chymification. Ale, therefore, when taken without such precautions, is liable to disturb the digestive organs. The ad- dition of the hop increases the value of the liquor, by the grateful stimulus which it imparts, and in some measure redeems it from those vices with which it might otherwise be charged. To those therefore whose diet is not very nutritive, ale may be considered not only as an innocent but as a salubrious article; and happy is that country whose labouring classes prefer such a beverage to the mischievous potations of ardent spirit. These remarks cannot, however, apply to the classes of the community who " fare sumptuously every day." They will not require a nutritive potation of such a character; and light wines have accord- ingly, in these days of luxury, very properly su- perseded its use : but we are not disposed to ex- tend this remark to its more humble companion, " table beer." We regard its dismissal from the tables of the great as a matter of regret; its slight but invigorating bitter is much better adapted to promote digestion than its more costly substitutes. But it should be soft and mild ; for when stale and hard it is likely to disturb the bowels, and occasion effects the very opposite to those it is intended to produce. Nor ought it to have too great a proportion of hops, but should be thorough- ly fermented and purified. Sydenham always took a glass of small beer at his meals, and he considered it as a preservative against gravel. The great division of malt liquors is into small beer, ale, and porter. The liquor called Ale was originally made of barley, malt, and yeast alone. There existed for a long time a strong prejudice against hops, which were considered as " pernicious weeds ;" but it is now generally admitted that they constitute the most valuable ingredient in malt liquors. Inde- pendently of the flavour and tonic virtues which they communicate, they precipitate, by means of their astringent principle, the vegetable mucilage, and thus remove from the beer the active princi- ple of its fermentation : without hops, therefore, we must either drink our malt liquors new and ropy, or old and sour. There are several varieties of ale, distinguishable by their colour : when the mall is slenderly dried, the ale is pale; or brown when the malt is more roasted or high dried. Porter.—This is made from high-dried malt, and differs from other malt liquors in the propor- tions of its ingredients, and by the peculiar man- ner in which it is manufactured. Much has been said upon the fraudulent adulteration of this arti- cle ; but we are inclined to believe that these state- ments have been exaggerated. Ardent Spirits.—The art of extracting alco- holic liquors by distillation from vinous liquors, must be regarded as the greatest curse ever inflicted upon human nature. The fatal effects of dram- drinking have been vividly depicted by numerous writers; and the awful truth has been too fre- \ quently illustrated to render any remarks in this [ place necessary. In a medical point of view, however, spirit may be considered as occasionally useful. Where it is taken in a diluted state, the mixture should always be made twelve hours be- fore it is used. Spirit and water do not easily combine ; and much of the force of the former is blunted by intimate incorporation with the latter, as we have already observed under the history of wine. We throw out this hint to those who are in the habit of drinking weak brandy and water at their meals: although the propriety of such £ practice is questionable. There are cases of dyspepsia in which wine and beer equally dis- agree with the stomach, producing acidity and other distressing symptoms: very weak spirit may, perhaps, in such cases, be taken with ad- vantage ; but its strength should be uniform, and no circumstances should induce the patient to in- crease the proportion of the spirit. The habit of drinking liqueurs cannot be too much reprobated: many of these cordials are impregnated with nar- cotic substances, which add to the noxious qua- lities of the spirit. Op Condiments.—These may be defined sub- stances which are, in themselves, incapable of nourishing the body, but which, in concert with our food, heighten its flavour, promote its diges- tion, or correct some, of its deleterious properties. The existence and necessity of such agents are more general and important than is generally sup- posed, and a philosophical 'examination of their modus operandi would disclose views of great and novel interest to the physician. The bitter principle which exists in the composition of grasses and of other plants, appears to be essen- tial to the digestive process of herbivorous animals, for when deprived of it they become diseased; and yet we are assured, by repeated experiment, that it passes through the alimentary canal without undergoing the least change; it can therefore only act as a stimulant in transitu, and affords an excel- lent example of a natural condiment. We are our- selves conscious of the invigorating effects of slight bitters upon our stomach, although civilization has, to a great degree, destroyed our natural taste for them, while, by improving our vegetable food, it has probably rendered such a stimulus unne- cessary. The Swiss peasant cheers himself amid the frigid solitude of his glaciers with a spirit dis- tilled from gentian, the extreme bitterness of which is relished with a glee that is quite unintel- ligible to those who are not accustomed to it. From the different nature of condiment, it has been usually divided into three classes, viz. the saline, the spicy or aromatic, and the oily* Suit appears to be a necessary and universal stimulus to animated beings; and its effects upon the vegetable as well as animal kingdom have furnished objects of the most interesting inquiry to the physiologist, the chemist, the physician, and the agriculturist. It appears to be a natural stimu- lant to the digestive organs of all warm-blooded animals, and they are instinctively led to immense distances in pursuit of it. This is strikingly ex- emplified in the avidity with which animals in a wild state seek the salt-pans of Africa and Ame- rica, and in the difficulties they will encounter to [ reach them: this cannot arise from accident or DIETETICS. 669 caprice, but from a powerful instinct, which, ' beyond control, compels them to seek at all risks I that which is salubrious. We are all sensible of J the effect of salt on the human body ; we know how unpalatable fresh meat and most vegetables are without it. One of the ill effects produced by j an unsalted diet is the generation of worms. In Ireland, where from the bad quality of the food J the lower classes are greatly infested with worms, a draught of salt and water is a popular and effi- cacious anthelmintic. Lord Somerville, in his Address to the Board of Agriculture, gave an interesting account of the effects of a punishment which formerly existed in Holland. *<■ The ancient laws of the country ordained men to be kept on bread alone, unmixed with salt, as the severest punishment that could be inflicted upon them in , their moist climate. The effect was horrible ; i these wretched criminals are said to have been devoured by worms engendered in their own sto- j machs." The wholesomeness and digestibility of our bread are undoubtedly much promoted by the addition of the salt which it so universally re- ceives.* If the utility of salt be thus established, it may be asked how it can happen that salted provisions should ever produce those diseases which expe- rience has shown to arise from their use. In ex- plaining the operation of suiting meat, and in ap- preciating the effects of such meat as food, it will . be necessary to advert to a chemical fact, which has not hitherto attracted the attention which its j importance merits. The salt thus combined with the animal fibre ought no longer to be considered as condiment; a chemical combination has taken place; and although it is difficult to explain the nature of the affinities which have been brought into action, or that of the compound to which \ they have given origin, it is sufficiently evident i that the texture of the fibre is so changed as to be J less nutritive as well as less digestible. If we are < called upon to produce any chemical evidence in support of such an assertion, we need only relate the experiment of M. Eller, who found, that if I salt and water be boiled in a copper vessel, the J solution will contain a notable quantity of that metal; whereas if, instead of heating a simple solution, the salt be previously mixed with beef, bacon, or fish, the fluid resulting from it will not contain an atom of copper. Does not this prove that the process of salting meat is something more than the mere saturation of the animal fibre with muriate of soda ? Vinegar, in small quantities, is a grateful and wholesome stimulant; it will often check the chemical fermentation of certain substances in the stomach, and prevent vegetable matter in its raw state from inducing flatulence; but its use requires caution, and in some morbid states of the system it is obviously improper. Fatty and gelatinous substances frequently appear to be rendered more digestible in the stomach by the addition of vine- gar, although it is difficult to offer either a chemi- cal or physiological explanation of the fact. The native vegetable acids may also be occasionally • A pound of salt is generally added to each bushel of flour. Hence it mav be presumed, that every adult con- sumes two ounces of sail per week, or six pounds and a half per annum, in bread only. substituted : the addition of lemon-juice to rich and glutinous soups renders them less liable to disagree with the stomach; and the custom of eating apple-sauce with pork is, undoubtedly, indebted for its origin to the same cause. We shall take this opportunity to observe that vinegar, if taken in considerable quantities, as is not un- frequently the case with young persons, to prevent the accumulation of fat, is highly injurious to the digestive organs; and, if the habit be long con- tinued, produces fatal marasmus. The aromatic condiments comprise the foreign spices, as pepper, cayenne pepper, cinnamon, nut- meg, cloves, ginger; and the indigenous herbs and roots, such as parsley, thyme, sage, garlic, leek, onion, horse-radish, mustard, &c. The former of these were not intended by nature for the inhabitants of temperate climes : they are heating and highly stimulant. We are, however, not anxious to give more weight to this objection than it deserves. Man is no longer the child of nature, or the passive inhabitant of any particular region : he ranges over every part of the globe, and elicits nourishment from the productions of every climate. It may be therefore necessary that he should accompany the ingestion of foreign aliment with foreign condiment. If we go to the East for tea, there is no reason why we should not go to the West for sugar. The dyspeptic invalid, however, should be cautious in their use; they may afford temporary benefit at the expense of permanent mischief. It has been well said that the best quality of spices is to stimulate the appetite, and their worst to destroy by insensible degrees the tone of the stomach. The intrinsic goodness of meats should always be suspected when they require spicy seasoning to compensate for their natural want of sapidity. But, mischiev- ous as the abuse of aromatic condiments may be, it is innocent in comparison with the custom of swallowing a quantity of brandy or an increased libation of wine to counteract the distress which supervenes on a too copious meal. Oil. — This, with butter, constitutes what are called the oleaginous condiments. Melted butter is, perhaps, the most injurious of all the inven- tions of cookery : oil, when used in extremely small quantities, as a seasoning to salads, appears to prevent their running into fermentation, and consequently obviates flatulency. II. On THE PERIOBS BEST AnAPTED FOR MEALS, AND ON THE INTERVALS WHICH SHOULD ELAPSE BETWEEN EACH. Having offered a history of alimentary sub- stances, and pointed out the general characters by which each species may be distinguished, we shall, in the next place, proceed to inquire into the vari- ous circumstances which may be capable, of modi- fying the effects of food upon the human body, so as to promote, retard, or altogether to suspend the digestion of it; and first, with regard to the peri- ods best adapted for meals. It is not extraordi- nary that a discrepancy of opinion should exist upon a question which involves so many fluctuat- ing circumstances. Controversy upon this, as upon many other subjects of diet, has engendered a disbelief in its importance, and this scepticism has given a plausible pretext for indulgence on the one hand, and protracted fasting on the other, 670 DIETETICS. as the wishes or habits of mankind may have ren- j dered most agreeable. We have been told that the best time for dining is, "for a rich man, when ] he can get an appetite, and for a poor man, when he can get food." But appetite in health is regu- lated by habit, and in disease it acts but as an imperfect monitor. Certain general principles, therefore, deduced from observation and experi- ence, must be laid down for our guidance, and these again in their application must be modified and adapted to the circumstances of every particu- lar case ; but before we enter upon this part of our subject, we must offer a few remarks upon the phenomena of hunger and thirst. To account for the well-known sensation of hunger, various hypotheses have been framed, which it is not our present purpose to examine. The physiologists of the present day would ap- pear to incline to the belief that it arises from the stimulant action of the gastric juice upon the nerves of the stomach; and to support this opinion, Dr. Wilson Philip relates the following experiment. A person in good health was pre- vailed upon to abstain from eating for more than twenty-four hours, and during that interval to in- crease the appetite by more than ordinary exer- cise. At the end of this time he was extremely hungry ; but, instead of eating, he excited vomit- ing by drinking warm water and irritating the fauces. The water returned mixed only with a ropy fluid, such as the gastric juice is described to be. After this operation, not only all desire to eat was removed, but a degree of disgust was ex- cited by seeing others eat. He, however, was prevailed upon to take a little bread and milk, which in a very short time ran into the acetous fermentation, as indicated by flatulence and eruc- tation. Now, if this experiment proves anything, it merely shows that disturbance of the stomach, or of the nervous arrangements which are subser- vient to it, will destroy appetite for food ; the ex- istence of nausea, short of vomiting, will produce the same effect, and yet in this latter case the gas- tric juice is not removed : so, again, if a narcotic be applied to the nerves, their power is paralyzed, and the sensation of hunger ceases. Such an effect is produced by the juice of tobacco, although by long habit the stomach may become indifferent to its operation. Whenever the Indians of Asia and America undertake a long journey, and are likely to be destitute of provisions, they mix the juice of tobacco with powdered shells in the form of small balls, which they retain in their mouths, the gradual solution of which serves to counteract the cravings of hunger. Sir Walter Scott tells us that " General Monk, not being able to procure any supper at Coltstream, was fain to have re- course to chewing tobacco to appease his hunger." In like manner we may explain the operation of spirit in taking away the appetite of those who are not accustomed to it; while those who indulge the habit receive its stimulant without its narcotic impression. Lord Byron entertained a great dread of becoming corpulent, and on that account fre- quently abstained from food for several days toge- ther, appeasing his hunger by a wafer and a glass of br.nuly. Although we do not mean to deny that the presence of a portion of gastric juice does not con- tribute to the sensation of hunger, it is quite evi- dent that the phenomenon is intimately connected with an energetic state of the nerves, occasioned by an interval of inactivity, during which, when the organs are in a healthy condition, the vital powers may be supposed to accumulate. We might even venture to question the agency of the stomach so far as to contend that the sensation of hunger is seated in the ganglionic system ; for we know from actual experiment that nausea is wholly independent of the stomach, since that sensation, as well as the spasm of retching, may be produced by the injection of tartar emetic into the veins of an animal, from which the stomach has been previously removed. Nausea, then, al- though, like hunger, it be referred to the stomach, is evidently independent of it; and if nausea can exist, why may not the opposite sensation of hunger, even though the animal should have lost its stomach by excision 1 Natural appetite, which is only the first degree of hunger, never appears to recur until the ab> ment previously introduced has been duly assimi- lated. It cannot, therefore, strictly speaking, be said to have an immediate reference to the state of the stomach; for although all the chyme may have long before passed out of that organ, if any delay or embarrassment occur in its ulterior changes, appetite will not return, since the ner- vous energy being engaged in their completion cannot accumulate in the stomach; on the con- trary, in certain diseases, as in tabes mesenterica, notwithstanding the presence of alimentary matter in the stomach, the appetite is never pacified, the subsequent processes being imperfect. These views are not introduced in this place for the purpose of encouraging fruitless speculation, but in order to establish a proposition of the highest importance in its relations to the theory of diet; viz. that the several processes by which food is converted into blood cannot be simultaneously performed with- out such an expenditure of vital energy as weak persons are unable to sustain without mischief. Thus, chylification would appear to require the quiescence of the stomach, and sanguification to be still more incompatible with the act of chymi- fication. If, therefore, the stomach be set to work during the latter stages of digestion, the processes will in weak persons be much disturbed, if not entirely suspended. Certain circumstances cause hunger to return at nearer intervals by accelerat- ing the nutritive process; while others, by pro- ducing an opposite tendency, lengthen such inter- vals. It is a well-known fact that if a person be in- terrupted in his meal for a quarter of an hour, he finds on resuming it that his appetite is gone, al- though he may not have eaten half the quantity which he required ; this probably arises from the food having entered upon those ulterior changes which are incompatible with the energy of the stomach. The feeling of thirst announces to the indivi- dual the necessity of introducing a certain quantity of liquid into the system, in order to repair the waste which the body has sustained in the exer- cise of its functions, or to impart a due degree of solubility to the aliments which have been taken. We accordingly find that excessive perspiration DIETETICS. 671 mcreases the demand for it, and that dry food is followed by the same effect. The sensation is usually referred to the throat and fauces, but its intensity does not bear any relation to the dryness of those parts; for in some cases, where the tongue, to its very root, is covered with a thick and dry crust, there is little thirst; while, on the other hand, it is frequently intolerable at the very time the mouth is surcharged with saliva. We are inclined to refer the sensation to the cardiac or splenic portion of the stomach.* Dr. Gardner has remarked that, in the case of a person who had cut through the oesophagus, several buckets- full of water were swallowed daily, and discharg- ed through the wound, without quenching the thirst, which was afterwards found to abate by the injection of diluted spirits into the stomach. All physicians advocate the necessity of regu- larity, both as regards the number of meals, and the periods at which they are taken. Those who have weak stomachs will, by such a system, not only digest more food, but will be less liable to those affections which arise from its imperfect as- similation ; because, as Dr. Darwin has justly observed, they have in such a case both the stimu- lus of the aliment they take, and the periodical habit to assist the process. The periods of hun- ger and thirst are undoubtedly catenated with certain portions of time, or degrees of exhaustion, or other diurnal habits of life ; and if the pain of hunger be not removed by taking food at the usual time, it is liable to cease until the next period of time or other habits recur. As these periods must vary according to circumstances in each indivi- dual, it frequently becomes necessary in civilized life to have recourse to intermediate meals, or luncheons ; but to the dyspeptic patient such in- dulgences are rarely to be permitted. It is the more necessary to impress this precept upon the minds of invalids, as the anxiety of friends and the popular errors which exist upon the subject are too apt to establish the mischievous though specious aphorism of Sir William Temple, that "the stomach of an invalid is like a schoolboy, always at mischief unless it be employed." By such a system the natural process of digestion must, if our preceding views be correct, be con- stantly disturbed, and the healthy action of the stomach, as evinced by the return of moderate appetite, entirely prevented. But though the ad- vantage of regular meals at stated periods is desi- rable, it has been much disputed how many ought to be allowed in the day : some physicians have considered one, others two, three, or even five necessary. It is, perhaps, impossible to lay down a general rule that shall apply to every particular case. In some persons the food rarely remains longer than three hours in the stomach ; in others four, five, or even six hours. It is evident, then, * Although the stomach is a single bag, it maybe con- sidered, with respect to its functions, as divisible into two distinct cavities; and these portions are, durini; the activity of the stomach, separated from each oilier by a peculiar muscular contraction. Thesetliaiubers . vident- ly appear to perform dilli-reiit offices in the pro; ss of digestion. The splenic portion would serin to separate from the food the superabundant water, ami then to transmit the former to the pyloric ilni.Mon, where it n i- dergoesits first gnat change. In the horse the mucoid membranes of ihe I wo extremities of the stomach present even a striking difference of structure. that the repetition of the meals ought to be regu- lated by this circumstance ; always avoiding the extreme of long fasting and repletion. Celsus recommends the healthy to take food rather twice than once in the day, and Sanctorius says, " that the body becomes more heavy and uneasy after six pounds taken at once than after eight taken at three meals," and that he who makes but one meal in the day, let him eat much or little, is pur- suing a system that must ultimately injure him. When Plato returned that memorable answer to the philosophers who inquired whether he had seen any thing remarkable in Trinacria, " vidi monstrum in natura, hominem bis saturatum in die," he referred rather to the quantity than to the repetition of the meal of Dionysius. In our opinion, where the individual takes moderate ex- ercise, three frugal meals may be allowed. It is reported that, when Alexander the Great turned away his cooks on proceeding upon a march, he observed that he had no further occasion for such assistants, as he carried with him superior cooks —a long morning's journey to create an appetite for his dinner, and a frugal dinner to give a relish to his supper. Breakfast is, perhaps, the most natural and not the least important of our meals : for, since many hours must have intervened since the pre- ceding repast, the stomach ought to be in a con- dition to receive a fresh supply of aliment. As all the food in the body has during the night been digested, we might presume that a person in | the morning ought to feel an appetite on rising ; this, however, is not always the fact: the energies of the stomach, although invigorated by repose, are not immediately called into action, especially in debilitated habits; it is therefore frequently advisable to allow an interval to pass before the meal. A question of some interest has arisen as to the propriety of taking a solid or liquid break- fast. We seem to have greatly departed from the custom of our hardy ancestors in this respect. A maid of hononr in the court of Elizabeth break- fasted upon beef and drank ale after it; while the sportsman and even the day-labourer of the pre- sent day frequently breakfasts upon tea. The periods of their meals, however, were so generally different from those of modern times, that we can- not establish any useful comparison between them without taking into consideration the collateral circumstances which must have influenced their operation. It will not be difficult to show that liquids at this meal are essentially necessary. To say nothing of the instinctive desire we all feel for them, it is evident that there is a certain acri- mony and rankness in all our secretions at that time; the breath has frequently a peculiar taint in the morning, which is not perceptible at sub- sequent periods of the day. The fluids of the body must have sustained a loss by perspiration, which experiments have shown to be double during sleep, a fact which in itself shows the pro- priety of a liquid breakfast. Dinner.—Among the Romans this was rather considered as a refreshment to prevent faintness, than as a meal to convey much nourishment; hut in modern times we need scarcely say that it is regarded as the principal meal, at which every species of luxurious gratification is indulged in. 672 DIETETICS. With regard to the proper period at which inva- lids should dine, physicians entertain but one opinion. This period is the middle of the day, or at about two or three o'clock, in order to afford a timely replenishment before the evening waning of the vital powers, and which naturally precedes the hour of rest. The exact period, however, of dinner must in some measure be directed with reference to the necessary habits of the patient, the nature and time of his breakfast, and, above all, to the rapidity or slowness of his digestion. Ought we to take liquids at our dinner ?— This question has been a fruitful source of con- troversy ; but it appears to us to be very easily settled. By drinking before a meal, we place the stomach in a very unfit condition for the duties it has to perform. By drinking during a meal, we shall assist digestion if the solid matter be of a nature to require it, and impede it if the quan- tity taken renders the mass too liquid. It is evi- dent that if the stomach be distended with fluid, the digestion of its solid contents must meet with impediment; its bulk will stimulate the muscular fibres to contract too rapidly, and thus to expel the food before it has undergone the necessary changes ; while at the same time, if the solid matter be diffused through a large quantity of liquid, it cannot be so easily acted upon by the gastric juice ; nor can it be readily converted into that pultaceous mass which appears to be a pre- liminary step to its digestion. On the other hand, if the food be too hard or dry, its necessary change by the churning of the stomach cannot be accom- plished. It therefore follows that different ali- ments will require different quantities of liquid to assist their chymification. Animal food will de- mand, of course, a greater quantity than vegetable food ; roasted than boiled meat, &c. The best, and perhaps the only test of the necessity of liquid during dinner is to be found in the sensations of the individual, which ought never to be disre- garded because they appear in opposition to some preconceived theory. If our food possess that degree of succulence which characterises digestible aliment, there will seldom be any occasion for drink ; but, on the contrary, where the mass is too dry, the stomach will give us notice of it by the creation of thirst. But, under any circum- stances, the quantity taken should be small; it is during the intervals of our solid meals that the liquid necessary for the repair of our fluids should be taken : and this brings us to the consideration of the next repast. Tea.—Theory and experience both conform in demonstrating the advantage which attends a liquid repast a few hours after dinner. At this period the chyle has entered its proper vessels, and is flowing into the blood, in order to undergo its final changes. Then it is that the stomach, having disposed of its charge, receives the whole- some draught with the greatest advantage ; then it is that the blood, impregnated with new ma- terials, requires the assistance of a diluent to com- plete their sanguification, an-1 to carry off the superfluous matter; and it is then that the kid- neys and the skin will require tin-* aid of addi- tional water to assist the performance of their functions. Sapper.—In the time of Elizabeth, the no- bility and gentry were accustomed to dine nt eleven, to sup between five and six, and to retire to rest at ten. It is therefore evident that any argument in favour of this meal, founded upon the healthy condition of our ancestors, cannot avail. By supper, in modern times, we mean a meal just before bed-time ; but as sleep is not favourable to every stage of digestion, it is very questionable whether retiring to rest with a full stomach can, under any circumstances, be salu- tary. During the first part of the process, or that of chymification, a person so situated may per- haps sleep quietly, unless, indeed, the morbid dis- tension of the stomach should impede respiration, and occasion distress; but when the food has pass- ed out of the stomach, and the processes of chy- lification and sanguification have been established, the natural propensity of the body is for activity, and the invalid awakes at this period, and remains in a feverish state for some hours. Upon this general principle, then, suppers, that is to say, hearty suppers, are to be avoided. The same objection cannot be urged against a light repast, which is often useful to dyspeptics ; and it has been truly and facetiously observed, that some in- valids need not put on their night-cap if they do not first bribe their stomachs to good behaviour. On the quantity of Food, that ought to be taken at different meals. — Nothing can be more absurd than to establish a rule of weight and measure upon such occasions. Individuals differ from each other so widely in their capacities for food, that to attempt the construction of a universal standard would be little less ab%urd than the practice of the philosophical tailors of Laputa, who, the reader will remember, wrought by mathe- matical calculation, and entertained a supreme contempt for those humble and illiterate fashioners who went to work by measuring the person of their customer ; but Gulliver tells us that the worst clothes he ever wore were constructed on abstract principles. How then, it may be asked, shall we be able to fix the proportion of food which it may be proper for an invalid to take ? By desiring the patient to attend carefully to the first feeling of satiety. There is a moment when the relish given by the appetite ceases; a single mouthful taken after this oppresses a weak sto- mach. If he eats slowly, and carefully attends to this feeling, he will never overload the stomach ; but, that such indication may not deceive him, let him remember to eat slowly and to masticate tho- roughly. This is an important condition; for when we eat too fast, we introduce a greater quantity of food into the stomach than the gas- tric juice can at once combine with ; the conse- quence of which will be, that appetite may con- tinue after the stomach has received more than it can well digest. On the conduct to he pursued previous and subsequent to Meals; and on the re- lations of Diet to the Non-naturals.__We do not intend to assert that Nature ever contem- plated the necessity of confining men to a certain routine of habits ; nor did she ever contemplate, as far as we can learn, the existence of those dis- eases which may render such discipline necessary. | We have in this place only to inquire into the habits which are most favourable or hostile to the DIETI process of digestion, and then to form a code for the direction of those who may stand in need of such artificial assistance. We have therefore to consider the influences of air, exercise, sleep, and the passions of the mind. Exercise in the open air is essential to the well- being of every one; but its degree must be regu- lated by circumstances. The interval between breakfast and dinner is the period for active exer- tion, and the enjoyment of it, when not attended with severe fatigue, will strengthen and invigorate all the functions of the body ; but it is important to remark that the valetudinarian and dyspeptic should never take his principal meal in a state of f^igue ; and yet what habit is more general ? Every body is impressed with the belief that after the sedentary occupation of the morning, to take a long and fatiguing walk will sharpen the appe- tite and invigorate the digestion : the consequence is obvious ; instead of curing, such a practice is calculated to perpetuate and even to aggravate a dyspeptic malady ; for the powers of digestion will be thus summoned at a period when the vital energy of the body is exhausted. We are anx- ious to be clearly understood upon this point: let it not, therefore, be supposed that we decry the use of moderate exercise before dinner; it is only the abuse of it we are so anxious to prevent. No person should sit down to a full meal unless he has previously inhaled the open air, and taken a quantity of exercise proportionate to his power of sustaining it without fatigue. If exercise be necessary previous to a meal, there is also a certain period after it at which the accomplishment of the last stage of digestion will be accelerated by it. When the chyle enters the blood, the body be- comes enlivened; while the stomach and small intestines, having been liberated from their bur- then, oppose no obstacle to the free indulgence of that desire for activity which Nature has thus in- stinctively excited for our benefit. Then it is that animals are roused from that repose into which they had subsided during the earlier stages of di- gestion, and betake themselves to action; then it is that civilized man feels an aptness for exertion, although he mistakes the nature and object of the impulse, and is inclined to regard it as nothing more than a healthy sensation, by which he is summoned to that occupation to which inclination or duty may prompt him. Thus, instead of be- ing bodily active, the studious man receives it as a summons to mental exertion ; the indolent man, perhaps, merely to sit up and enjoy himself; the libertine to commence his libations ; and the vo- tary of fashion to attend the crowded circles of gaiety and dissipation. In short, this feeling of renovated energy is used or abused in a thousand ways by different individuals, without their ever dreaming that bod. ly exercise, and that alone, is implied by it. The result of this mistake is, that imperfect assimilation and all its train of evils fol- low. In this respect our ancestors enjoyed a great advantage from their early hours; they were enabled by them to take exercise at the most advantageous periods of the day; even the hall-room, which in our days might be term- ed Death's ante-chamber, was not injurious ;— with them the dance commenced at six and ter- Vol. I. — 85 3 a TICS. 673 minated at eleven; with us it begins at eleven and ends at six ! If exercise be useful during the period of san- guification, pure air is not less so ; and we may take this opportunity of protesting against the custom of frequenting ciowded and ill-ventilated apartments at the very hour when the body requires the purest air for the sanguification of the aliment which has been recently taken into it. Sleeping after dinner is a practice of very ques- tionable propriety : it is true that the inhabitants of many southern climates indulge in it with im- punity ; but it does not appear essential in this country, where animal food is used in such con- siderable quantities. Its effect is to hurry on the different stages of digestion ; and hence the fever and state of excitement in which the person not J unfrequently awakes. In states of disease, it may occasionally be useful, and the recumbent posture may expedite the passage of the aliment out of the stomach ; but we should recommend those i who indulge in such a habit to remove all ligatures from the body. Passions of the mind, such as fear, anxiety, and rage, are well known to affect the nervous system, and, through that medium, the stomach and func- tions of the digestive organs ; and so immediately j are their consequences experienced, that a person i receiving unpleasant intelligence at the hour of repast is incapable of eating a morsel, whatever might have been the appetite before such commu- nication. " Bead o'er this ; And after this; and then to breakfast With what appetite you may." In directing our attention to the excretions, we must not overlook the sympathy subsisting be- j tween the skin and stomach. If the cutaneous vessels be universally excited, and this excitation I be long continued, they will at length fall into a state of indirect debility, whence a sense of faint- ness, loss of appetite, and the inability of digest- ing solid food will be experienced. This fact ex- plains the diminished appetite of which persons complain in hot weather, and that universal cus- tom in tropical climates of combining the food with large quantities of aromatic stimulants. One of the most striking instances indicative of this consent between the skin and the stomach is to be found in cases where cold or wet has been ap- plied to the lower extremities. The following is an extract from a letter received by the writer of this article, from Dr. John Badeley, of Chelms- | ford :—" A gentleman who consulted my father, i complained that on getting out of bed in the morn- | ing, and putting on his leather breeches, he con- stantly vomited, from the sensation of cold thus occasioned. My father recommended him to take a glassful of cold water before he commenced dressing, and it was found effectual. The gentle- man never afterwards vomited upon these occa- 1 sions." I But it is necessary, to conclude this essay. We have endeavoured, in the shortest possible com- pass, to develope the philosophy of the subject of dietetics, and, as far as our present knowledge ex- tends, to point out the chemical and physical va- rieties of structure and composition which confer | upon different articles of nourishment their rela- 674 DISEASE. tive, nutritive, and digestible qualities. In the article Regimen we shall endeavour to apply this knowledge to the treatment of individual diseases. No general rule can be given for the guidance of the physician in such cases. Every such attempt must be a failure: it may foster quackery, and perpetuate popular error, but it can never advance the progress of that pure and simple science which it is the object of these pages to inculcate. J. A. Paris. DILATATION OF BRONCHI—See Bron- chitis, Chronic. [DILATATION OF THE HEART.—See Heart, Dilatation of the.] DISEASE. Disease is disordered action of any part of the machinery of the body, [or it is, an altered condition of structure, or function, or both, in some part of the organism.] Its primary effects, or perhaps we would say, its primary pal- pable phenomena, are impeded or disordered func- tions ; and of these the results are alterations of structure, and various symptoms or signs indicative of functional and of structural changes. There is a state of the different systems of which the body is composed, in which all the functions of life are performed with comfort and ease, and a ! fluenza. No doubt can be entertained of the sense of well-being. This is the state of health. I agency of such atmospherical influences in the Whenever any bodily or mental function is not I production of the common eruptive disorders; and performed thus harmoniously, there is an inter- of one at least of the disorders characterised by ruption of this state, however slight the departure irritation of a particular portion of the nervous from the condition of health may be. The first i system (the respiratory), and by spasm,—circum- symptom of this slight disease, for such it is, is | stances exemplified by the hooping-cough. The mere discomfort. As the disorder proceeds, if it direct influence of the air on the nervous system are so many causes of disease. They are found in the elements by which he is surrounded ; in the food on which he subsists; in excess or defect of voluntary exercise ; and in the nature of bis mind, sensations, and affections, which subjects him to various kinds of risk by prompting various actions and enterprises, and which is susceptible of impressions as well as capable of originating such actions. Man is also liable to connate and inherited defects, and to diseases resulting from the natural decay of his bodily frame. The element to which man is chiefly and at all times exposed, is the air. Its variable tempe- rature, dryness, and moisture; ite alternations of calmness and commotion; and probably, also, its variable electrical states; not only immediately affect the surface and the respiratory organs, but through the latter the blood, and through that fluid the energy of all parts of the system. Some of the variations seem to have a direct influence on the nervous system ; and there are presumable properties in the air, yet unknown save in their destructive effects, which are largely concerned in the production of our common continued fevers, the yellow fever, the plague, the intermittents of fenny countries, cholera, and what is called in- does proceed, from this slight beginning, the dis- comfort is succeeded by pain and various other circumstances, which are all consequently so many symptoms of disease. Thus the slightest disor- dered action may produce only inconvenience ; as nausea, vertigo, pruritus: and increased disordered is not easily proved; but to this, or to some effect produced on the fluids or solids of the body, to- gether or separately, must be ascribed the varia- tions of feeling and spirits experienced by so many individuals in variable states of the weather, and the suicidal despondency which medical travellers action will produce increased inconvenience ; vo- i have found to be induced by the sirocco. (Dr. miting, loss of sense, cutaneous inflammation, J. Johnson.) The condition of certain structures with the additional symptoms of pain. On this aggravated 6tate changes of structure supervene. It occasionally happens that functional disorders, because they in such cases affect parts of a low degree of sensibility, proceed far, even to struc- of the body, and perhaps of their nerves, is seen in the course of the seasons to be materially af- fected by certain states of the atmosphere: the effects being sometimes, apparently, merely the result of temperature, as in the catarrhs, and dis- tural alteration, with nothing more than symptoms ! orders of the respiratory and circulating appara- of occasional discomfort; but these instances are I tus in the cold weather of severe winters ; but at not frequent. Compatible with the state of health, also, are considerable varieties in the performance of cer- other times more obscure, as in the irritability of the mucous membrane of the stomach and intes- tines in the summer and autumn, of which the tain functions. They do not interrupt health so j consequences are periodical dyspepsia, gastric far as to produce even discomfort. The pulse of some individuals is never beyond 50, and of others never below 110. In some the function of diges- tion is more rapidly and actively performed than in others : and the intellectual alacrity of different persons is well known to be widely different, yet without disease. But when the food is not di- gested without discomfort or pain, or the circula- tion not carried on, or the mental movements not made, without similar results; when the appe- fevers, diarrhcea, dysentery, and cholera. Of dis- eases thus obscurely arising, some, peculiar to par- titular localities, are called endemic ; others, ap- pearing and disappearing at particular seasons with some regularity, are called epidemic, and many of the latter become under certain circum- stances communicable from one individual to an- other. Several of the occupations of man in civilised countries are carried on in confined and ill-venti- tite is lost, when there is fainting, when there lated places, where the mere assemblage of many is privation or other affection of any of the sensa- ' persons deteriorates the quality of the air : the tions or mental faculties ; then there is disease. I effect of breathing this is very injurious to health, The least consideration shows us that man is ! and a very common cause of disease. The influ- ex posed to various circumstances capable of dis- i ence of a high temperature, combined with exces- ordering his functions, and all these circumstances | sive moisture, has been abundantly experienced in DISEASE. 675 the diseases incidental to tropical climates. There i are also occupations in the course of which light particles of foreign matter are mingled with the air and inspired ; as needle-pointing, grinding of | corn, and mason's work; and these particles cause irritation and disease. j In the quality and in the quantity of food are found also the causes of disease. Some kinds of food produce disorder by their stimulating proper- j ties, and some by otherwise inducing departures from healthy processes, as in the example of cal- j culous formations in the kidneys. Man is equally disordered by excess and defect of nutrition. Excess or defect of voluntary exercise and rest affects him no less. It is the rule of nature that voluntary muscular action cannot be neglected with impunity ; and its excess produces direct ex- haustion. Many familiar facts, not uninteresting to the medical observer, illustrate the effects of certain species and measures of diet, and peculiar kinds and degrees of exercise, upon the human body. The corpulence and fatness of coachmen and farmers, and the thinness of students and of foot- soldiers, may afford him instruction. But the effects of what is termed training, both in increas- ing and decreasing the bulk and strength of the body, and the vigour of the mind, are more espe- cially deserving of attention. By the administra- tion of dry and very nutritious food ; by a certain degree of exercise in the open air; by allowing a moderate portion of sleep ; and by avoiding every kind of excess; assisted, however, it should be said, by great attention to the state of the surface, and by a little preparatory purgative medicine; the athlete of old, and the prize-fighters of modern times, have been accustomed to attain such a cor- poreal condition in the course of six or eight weeks as to endure great fatigue, to breathe freely and fully under extreme exertion, to bear violent blows on the head without giddiness, and to incur se- vere wounds without danger or long inconveni- ence. The appetite, after such a system of train- ing, becomes great; the skin becomes of a better colour; and the shape of the body improves. A man thus disciplined can not only run twenty or thirty miles with ease, or walk a hundred, but can face dangers which would before have appalled him ; and wrestle or contend advantageously with an assailant by whose strength he would previ- ously have been overpowered. It is said, too, that the perceptions become more acute, and the mental faculties more active ; but such conse- quences are of course not always observed among those who are commonly the subjects of training, although in their gaming devices they not unfre- quently show great acuteness and power of calcu- lation. These effects of training are commonly very transient, and repeated or excessive training seems to shorten human life. It is a question, however, how far this supposed hurtful effect of training is to be ascribed to the intemperate habits of the persons usually submitting to training. Race-horses and game-cocks, which are also sub- jected to particular training, are not found to be shorter-lived than other animals of the same spe- cies. By methods entirely opposite, the reduction of strength and of bulk may be effected in a very short space of time. The boys employed as jockeys at Doncaster and Newmarket are some- times reduced twelve or sixteen pounds in weight in the course of ten days, in order to ride a par- ticular race. They are not allowed during this preparation to have meat, or wine, or ale; but live on fish, and puddings, and bread and butter: they have tea at night, but nothing to eat with it. With this slender diet is conjoined strong exercise in thick and heavy clothing. After the race is run, the jockey is allowed to indulge himself; and it is said that as much as nine pounds in weight have been regained in eighteen hours. The effects of this reduction of weight and strength on the brain, as exemplified in the intellectual manifesta- tions, have not been noticed ; but it is said that the constitution is often ruined by these vicissi- tudes. Many jockeys may be observed to be stunted in growth, and to have, even in the prime of life, the dry and withered appearance of pre- mature old age. It is worthy to be remarked, that not only do excess in diet and extreme abstinence, too much rest and excessive fatigue, extremes of heat and extremes of cold, disorder the body; but that they all seem, when carried to the utmost, to affect the body in the same, or nearly the same manner. All (perhaps by impairing the functions of the nervous and vascular systems) eventually induce those disturbed actions which constitute febrile disorder. In fact, what is called re-action, under most circumstances, consists of the establishment of actions tending to febrile or inflammatory pro- cesses ; and probably the converse, namely, that inflammations and fevers are commonly intended to rid the body of some inconvenience, is not far from the truth. The great gift of the mind, also, by which man is so greatly raised above the lower animals—by which he inquires, improves, records his improve- ments, and looks beyond this life—is a gift that his imperfect nature cannot bear without the tribute of occasional inconveniences, from which the less privileged animals are exempt. Its inor- dinate exertion, and the vehement impressions of which it is susceptible, exhaust the nervous energy, or impair the nervous actions, or alter the actual condition of the nerve ; and thus deprive the physical part of the system of some of its power, increase its susceptibility, disturb the pro- cesses which should be performed in the different bodily organs, and bring on disease, or gradually enfeeble the whole system. From such causes we perceive, in different cases, various irregular actions, chiefly exemplified in the muscles,—agi- tation, tremor, faltering voice, unsteady gait, spasm, hysteria, epilepsy ;—or exemplifications of dimin- ished power, as in the various shades of paralysis. By sloth and negligence, or by irregularity and prodigality of application, the powers of the mind itself are equally impaired in some cases, and in others disturbed. Sudden and excessive joy ex- hausts the mental and nervous power at once; and sudden and overwhelming sorrow oppresses both beyond recovery, producing a state which is some- times followed by that deep sleep which restores the capacity of endurance, and sometimes by that sleep which ends all worldly suffering. The influence of sudden mental impressions oq 676 DISEASE. the circulation, in whatever way this is exerted, is evident enough in numerous instances. Their power in the production of that unequal distribu- tion of blood called determination is conspicuously seen in the simple act of blushing. Violent anger, or a sense of shame, causes the smaller vessels of the face and neck to be instantaneously injected with blood. By similar, but more violent effects, anger has fed to apoplexy ; and this passion is seen to render the face red in some individuals and pale in others. Fear commonly produces paleness, and extreme fear may induce death. The functions of the lungs may be affected, or at least the respiratory exertions are quickened, by surprise or other emotion ; and simultaneous pal- pitations show that the heart responds to the same influences; or its sympathy may produce some suspension of its actions, and syncope ensue : the faltering speech and the trembling limbs on some occasions, and the increased speed and strength exhibited on others, equally show how much the muscular energy may be influenced by temporary states of the mind. The gushing of tears in states of sorrow ; the diarrhoea and copious renal secretion under the action of fear or vexation; the sudden appearance of gout and of cutaneous eruptions in circumstances productive of great mental disturbance; the profuse perspirations, and the altered colour of the hair sometimes induced ; are all illustrations of the operation of the same class of causes. Long-continued depression of mind, or long anxiety, produces effects which are deeper and less immediately visible. The nervous and the vascular system seem equally to suffer; and habi- tual disorder of some of the functions, going on to the structural alteration of some organ, is the consequence. Chronic determination to the vessels of the stomach or lungs; or to the liver, or intes- tines ; or to the heart, or to the brain itself, are common results. Obstinate dyspepsia, attacks of asthma, permanent mischief to the hepatic and intestinal functions, or some variety of mental disorder, are among the modes in which such results are manifested : as is also a slow increase in the size, or change in some part of the struc- ture, of the heart itself; curiously according with that strong and melancholy expression, that the person thus destroyed has " died of a broken heart." On the other hand, need' any one be informed of the happy effects of a tranquil state of mind, or of the improved health which is brought by complete relief from heavy anxiety ? The amend- ed appetite, the better sleep, the improved com- plexion, the increased nutrition, which follow in the train of cheerfulness, must be familiar to the most superficial observation. The diseases produced by a disordered imagina- tion require only to be mentioned. There is a principle in the human body which enables it, when not previously disordered, to support and resist the influences of all the agents of disease up to a certain point. By this principle, which has been called the conservative principle, it is enabled to endure great and even sudden changes of temperature, and is secured for a time against noxious atmospheric influences. Great variety of food can not only be borne without inconvenience, but appears to be salutary; and occasional imprudences, as regards both excess and fasting, will, in a state of perfect health, pro- duce no permanent uneasiness. So also exercise may be taken, even to the production of extreme fatigue, or we may devote ourselves to long-con- tinued sedentary study, and yet remain well for a time ; and it is familiarly seen that neglect of proper rest often passes unpunished. It is the same with respect to the mind. When we are in perfect health, the various trials met with in the world ; the joys, the sorrows, the anxieties, which by turns affect us, are met with steadiness and fortitude, and pass away without disturbing the equanimity of that part of the system on which they make their transient impression. Leisure or complete idleness may also be interchanged with severe or varied mental application, and the health of the mind still be maintained. But when, by the prolonged or inordinate im- pression of some of the causes of disease already enumerated, or by other causes of disease which remain to be mentioned, the vital power is impair- ed in any one organ ; when, for instance, the gastric, pulmonary, or cutaneous functions, or the faculties of the mind, begin to show a little inter- ruption of vigour and regularity, even the ordinary objects with which the especial function is habi- tually concerned become exciting causes of dis- ease. Not only extremes and sudden varieties, but the common air, the ordinary kind and mea sure of food and drink, the customary exercise, and the daily excitements and depressions of social life, become so many sources of irritation: all those things which have occasionally been de- fined the sources of vital motion, — all external stimuli, all ideas of the mind, and volition,—then become causes of actual disease. Besides the causes of disease to which man is by his position constantly exposed, there are others incidental to his frame itself. A heart naturally feeble, or disproportionately small, is inconsistent with health. In every part of the globe, although more in some parts than in others, the species is subject to occasional deformities, some of which, as a contracted cranium or thorax, interfere with the most important functions, and impede their just performance. Very serious diseases arise also, in the course of life, from disordered actions, of which the causes are often entirely unknown; such are those departures from healthy deposition denominated cancer, tubercle, fungus nematodes; as well as the production of parasitic animals in certain structures. It is also very often seen that one disease will produce a second, not unfrequently more severe and dangerous. In this way some of the morbid formations just spoken of are occasionally induced; as that of pulmonary tubercle after a severe attack of catarrh, or after hooping-cough, or fever, or the measles. There is so close a connection between the different functions of the body, and between these and the mind, that no function can be long or very severely disordered without involving the disorder of another. This is particularly observa- ble in affections of the respiratory and circulating systems, but is existent, in a greater or less de- gree, with respect to all the rest. As fever is a disease which most deeply affects all the functions DISEASE. 677 of the body, it more than any other leaves a dis- position to various forms of disease ; sometimes to disease in the orsrans of locomotion, sometimes to disease of the lungs, and very often to diseases dependent on serious impairment of the nervous system, as paralysis or fatuity. The most numer- ous instances, however, of disease following dis- ease, are furnished by irritations, various in kind and in degree, of the intestiml mucous membrane ; which are so largely concerned in fevers as by some pathologists to be considered as their sole cause, and which doubtless induce every variety of irritation in the vascular apparatus of different tissues, from simple determination to common or tQ specific inflammation ; aggravating also, and often alone producing, all the varieties of nervous and spasmodic affections ; and being most widely concerned in the establishment of local disorders of every description, from a simple papular erup- tion to erysipelas, or to ulceration and deep de- struction of parts. The sympathies subsisting between the liver and the brain, and, more re- markably, between the uterus and the whole ner- vous system, produce phenomena from which the list of illustrations might be greatly swelled. Some diseases, chiefly such as exclusively affect glands, will in succession attack various parts. When tubercles exist in the lungs, they often also exist in several other situations, as in the mesen- teric glands, in the glands of the intestines, in the uterus, in the liver, in the kidneys, even in the heart. The term malignant has been, although with no very settled meaning, applied to such af- fections, and most frequently to cancer and fungus hsmatodes, which, when once existing in any part, are imagined by some pathologists to spread to other parts, and especially to other glands, by absorption. It is at least certain that such dis- eases seem to extend themselves in succession from the structure first attacked. The cause is not so clear as the fact is certain. It may be, that a general predisposition existing to a specific form of disease, the absorption, which unquestionably takes place, of diseased matter, acts only by ap- plying an irritant or exciting cause to other parts, as sufficient as otlier irritants, but not more suffi- cient than they, to disorder the glands through which it passes ; and which glands, when irritated and disordered, run into the disease to which they are by original constitution predisposed. Or the ilisease may be simultaneous in many parts, al- though unequally ad\anced. With respect to tubercles, however, when they exist in other parts of the body than the lungs, it may, we believe, l>e always predicated that they will also be found in the lungs themselves, and in a more advanced state. It is not to be forgotten, moreover, that the means employed to cure diseases are not always trinities* of producing others. Nearly every kind of medicine induces a temporary state which is really a state of disease, of which the intention ■lid effect is to relieve diseases more serious or less controllable. The excessive employment, therefore, of any kind of medicine may induce Immanent or at least serious disease. Thus drastic purgatives will bring on hemorrhoids; mercury will hasten the progress of phthisis ; al- kalies will irritate the digestive mucous mem-. 3a* brane; and all the narcotics will obtund the sensations and cloud the intellect. There is the strongest reason to believe that many nervous affections are exasperated by the habitual employ- ment of mercurial purgatives; iodine has some- times caused more obvious nervous irritations ; the nitrate of silver produces a permanent disease of the skin, limited, however, to an affection of its colour. Old age, naturally impairing the vigour of every function, necessarily exposes every function to disorder from common causes. In the best constructed body, the failure of the human frame must begin somewhere. Even in those rare cases in which extreme old age seems to be borne with- out disease, there is commonly particular impair- ment of some function or other for some time before all the functions cease. Long before death, the diminution of muscular power generally be- comes evident. A marked failure in the powers of the stomach is still more common. The in- conveniences of this time of life have, however, been eloquently enumerated in the article Age. The terms applied to all these different causes of di.ease, and the arrangement of them, have oc- casioned much very useless dispute. It is time that such scholastic trifling should be abandoned. What was defined, we believe first by Gaubius, as the proximate cause, which when present con- stituted the disease, when taken away removed it, and, when changed, changed it, either means nothing, or means the first of the effects of the cause of disease. Two things are plainly necessary for the pro- duction of disease ; a cause which acts on some organ, and a disposition in the organ to be acted upon. Two kinds of causes, then, and two only, are plainly concerned in the production of dis- ease ; a cause which predisposes, and a cause which excites. This may be illustrated by the single instance of typhous fever. One man is affected with typhous fever, and his neighbours escape. The exciting cause of the fever is sup- posed to be something peculiar in the air. But his neighbours have been exposed to the same peculiarity, and are not affected with fever. We explain this by saying that his health was not previously good ; that he was not in a state to resist the influence of the cause. This presumed disorder of his health was in this instance, then, the cause which predisposed him to the influence of the exciting cause of the fever. In the same way we see, of half a dozen persons simultane- ously exposed to cold and moisture, one becomes affected with sore throat, one with pleurisy, and one with rheumatism ; and the rest may continue well. The exciting cause was present to all, but a predisposing cause existed only in some, and was different in each of those in whom it did exist. If we retain the term proximate cause, it sig- nifies, in these cases, the pathological condition of the throat, the pleura, or the joints ; but we think the term may be advantageously banisheu from medicine. The chances and the characters of disease are always in proportion to the force of the exciting cause, and to the degree of the susceptibility to its operation. Of several persons suffering from 678 DISEASE. what is called determination of blood to the head, one may have vertigo, another pain ; one may have a fit of epilepsy, and one die apoplectic. The difference in the effect may be occasioned by a difference in the power of the exciting cause, or in the violence of the determination ; or, the de- termination being equally violent in all, the dif- ferent effect may depend on the peculiar suscep- tibility of each. There are certain cases in which disease appears to be produced simply by the application of an exciting cause, without the existence of a cause predisposing. There are others in which an ex- citing cause often seems to be wanting. These inconsistent phenomena, however, are to be as- cribed to our imperfect knowledge of some of the causes. A violent burn, a wound, or other acci- dent, will produce inflammation of various tissues, with no other predisposing cause than the nature of the human constitution. A child, in a particu- lar condition of atmosphere, will become affected with hooping-cough or measles ; and the predispo- sition is here also inherent in the constitution of the body. When the predisposition is removed, as in ordinary cases it is, by the occurrence of these disorders, the child may be exposed to the exciting cause, the peculiar condition of the air, with complete impunity. The cases in which disease seems to arise without an exciting cause, are chiefly those of morbid formations, in which such cause exists in the supervention of certain actions not yet understood. Forms of Disease.—Diseases, however various or complicated, or whatever are their terminations, admit of a division into two great primary classes; the first comprehending all disorders of function • the second all morbid products. Disorders of Function.—The view taken of this class by the general pathologist is one which is continually enlarging with the progressive im- provement of physiology. Its leading features may be spoken of in connection with the two most important symptoms of the body, the vascular and the nervous. Nearly every disordered action which can be conceived to exist, must be intimately con- nected with some irregularity in one or both of these systems. 1. In the vascular system we observe, a. local determinations or local accumulations of blood, productive of an excess of supply, with excitement of the part supplied in excess; or congestion, with oppression of the part congested, b. Local defec- tive supply of blood, producing or contributing to produce, defective secretions, defective energy, external discoloration, and a tendency to other disordered actions. Of these may be mentioned as examples, defective supply to the breasts or uterus in feeble women ; to the hair in old or sickly persons; to the brain and other organs in those convalescent from fever; and to the feet in diseased or aged persons, with a tendency to mor- tification, c. General excess of blood, or plethora ; the results of which are very various : e.g. increase of natural secretions, exhalations, and the vigour of different functions ; irregular actions ; excessive growths ; and, perhaps, other morbid formations. d. General defect of blood, or anaemia, e. The state of the blood-vessels in inflammation, whether common or specific, as in croup, &c. f. The state or actions of the blood-vessels in misplaced and new formations, including altered conditions of the blood contained in them. 2. In the nervous system we equally observe excess, defect, and irregularity of distribution. a. Local excess of nervous power; a state often accompanied with excessive sanguineous supply, but not invariably. To this excess of nervous power we cannot but attribute some of the in- stances of increased sensations and increased mus- cular actions in maniacal and hysterical persons. In the cases of increased secretions, increased ab- sorption, increased nutrition, and increased evacu- ations ; comprising the unusual flow of tears, or bile, or urine; the sudden disappearance of dropsi- cal accumulations ; hypertrophy of organs; diar- rhoea, and excessive perspiration ; a mixed expla- nation must be admitted : and in most of these circumstances, or perhaps in all except that of in- creased absorption, there appears to be a simulta- neous excitement of the nerves and the blood- vessels, b. So, also, the general excess of nervous power, or general nervous excitement, is not often seen distinct from excitement of the vascular sys- tem. Either, first existing, seems to induce the other. The nervous excitement may, however, exist first, and therefore separately, e. The gene- ral defect of nervous power is shown in the weary and exhausted, and in some forms of incipient paralysis. It is observed in many other instances, but generally co-existing with defective power of the vascular system, d. Local defect of nervous power is seen in persons affected with tremors, chorea, and partial paralysis; in idiots and luna- tics, whose intellectual actions are weak, impeded, or disordered, whilst their digestive powers are often unimpaired or even increased. It is observ- able also in the sick, the feeble, and the aged, and is one of the most ordinary precursors of death. The instances of deficient secretions, deficient nu- trition, and deficient evacuations, are, as the reader will suppose after what has already been said, to be viewed generally as the consequences of a simultaneous defect in the nervous and vascular actions. If it be admitted that the action of the absorbents depends on the nerves, deficient ab- sorption would in some instances appear to depend on defective nervous supply to the absorbent ves- sels. It is highly probable that some of the dis- orders of the function of respiration depend on deficient actions in the respiratory nerves. In some of the instances of chorea, as in tetanus, and in hydrophobic convulsions, the disorder of the. nervous system probably consists of excess, or of irregularity, rather than of defect, e. There is, apparently, a morbid condition of the nerves in all inflammations, and evidently in some, as in gout. f. There are probably disordered nervous actions, in no degree yet understood, concerned in misplaced and in new formations, including altered states of the blood itself. One very important example of general disor- dered action has been left out of this enumeration, namely, fever. Its place must depend on the yet undecided question of its actual nature. The vascular and the nervous depression, and the sub- sequent^ excitement of both the blood-vessels and nerves, are sufficiently evident. But not only is the order of these phenomena yet undetermined, DISEASE. 679 but their relation to a primary impairment of the vitality of the blood at least not disproved. For this reason we pass on to the second great class of diseases, or morbid products. Morbid Products—These may exist in the solid or in the fluid components of the body. They probably seldom arise from disorder of one of the great systems without coexisting disorder of the other. In their characters they vary exceedingly, as will be made apparent by the following, which is still an imperfect enumeration of them. a. The effects of simple determination of blood, or local excess, which seems to be not only in many cases an increase of natural discharges, but alterations in their properties. These have not been very closely investigated. The sudden, pro- fuse, and watery discharge from the mucous mem- brane of the nostrils incidental to some indivi- duals from slight causes, and distinct from common coryza, affords an example of this class ; and sud- den evacuations from the skin, or bowels, may be also mentioned. The redundant growth, or hy- pertrophy of organs, demands, for one of its ac- companiments, or rather one of its causes, this increased determination of sanguineous material; but such departures from the natural state shonld perhaps be classed in another division (c). Active hemorrhages are another consequence of increased determination to particular parts. b. The effects of inflammation ;—serum, lymph, false membranes on serous surfaces, pus, thicken- ings of parts by intestinal depositions, gouty con- cretions, the diphtheritic formations on mucous membranes, as in croup, and in inflammation of the mucous lining of the intestines or the vagina; and the peculiar matter found in scrofulous glands. c. Natural secretions or formations misplaced; —bone in soft parts, as in the membranes of the brain, in the heart, in the blood-vessels; fat about the heart, or in the substance of the liver; mis- placed fibrous tissue, cartilage, cellular tissue, hair, nails, serous tissue (in certain tumous, Bichat,) mucous tissue (in fistulas, Hunter,) enamel (in some diseases of the joints), synovial membrane (in false articulations), arteries, veins, and nerves (in some tumours). These misplaced productions are often imperfect. They do not necessarily en- danger life, although they are often inconvenient, and sometimes dangerous, in consequence of their situation or the size to which they attain. In certain cases they are formed for the preservation of life ; as in the case of the fibrous masses formed in aneurism, and of the cysts or boundaries of abscesses. d. Altered secretions; — soft or fragile bone; acrid bile; the disorders of the urine accompany- in? calculous formations. e. New formations, not the product of inflam- mation. In this class may be placed the various tumours—common, adipose, pancreatic, mammary, and tuberculated sarcoma ; and encysted and os- seous tumours ; all of which are of a local char- acter, and many of which coexist in some in- stances, as in certain enlargements of the ovaria. To these must be added the more serious forma- tions connected with some taint or fault in the constitution ; as scirrhus, tubercles, scrofulous en- largements, encephaloid tumours or fungus hsema- todes, and melanosis. Hydatids, worms, diseased exhalations, (as ascites, in disorder of the liver,*) and changes in the nature of the blood itself, be- long also to this class; and also the calcareous productions found in the lungs and bronchial glands. Many of the products under this head are dangerous to life. Reacting on the imperfect constitution in which they have originated, they occasion fever, various functional irregularities, emaciation, and death. They are frequently ac- companied by inflammation, the supervention of which appears to accelerate their progress; but in their origin, in their first symptoms, and in the wide difference existing between them and the ordinary products of any of the forms of inflam- mation which are the results of accidents, or can be excited by artificial means, we have so many reasons for ascribing them to processes quite dis- tinct from the inflammatory process. Theories of Disease. — These observations bring us immediately to the great question of the origin of these important departures from health; not only as regards the new products of disease, but the misplacements and excess and depravation of some of the natural products ; the solution of which cannot precede the determination of some unsettled questions in physiology. When the laws and processes of secretion are clearly demon- strated, the next step will be an accurate know- ledge of the diseased actions in which morbid pro- ducts originate. The alterations occurring in the fluid parts of the body, but particularly in the blood, which once attracted so much attention as to be the general basis of a pathological system, have recently, after experiencing the capricious neglect to which many doctrines containing much truth have at different periods been subjected, again drawn towards them the anxious attention of philosophical physicians. (See the article Blood.) The vital and, as it were, independent properties of the blood are no longer overlooked, and the important office per- formed by this fluid in relation to the secretions, an office extending beyond the mere supply of a material for their formation, directs the inquiries of the pathologist towards those intimate changes which, taking place within the arteries, or even in organs contributing to the unexplained function of the harniatosis, are the real causes of the sin- gular and abnormal products presented by various diseases. Thus we may in the present time per- ceive the dawn of a new humoral pathology, more correct, and at the same time less exclusive, than that which from the age of Hippocrates down to nearly the end of the seventeenth century pre- vailed throughout all the schools and doctrines of medicine. Without reverting to the dreams of the mathematical physicians, the doctrine which ascribed so many of the phenomena of disease to the moving powers, will not be discarded ; and even the first changes traceable in the blood itself may be acknowledged to depend upon irregulari- ties in actions of which the very existence is yet in the utmost degree obscure. When it is considered that five-sixths of the materials of the body are fluid; that all the mate- rials even of the solid parts primarily exist in a * In a case of hypertrophy of the hpart, the patient's perspiration tinged his linen, and the lining of his hat, of a red colour. 680 DISEASE. fluid state, and are again reduced to fluidity before their ultimate removal; it is quite in vain to deny the importance of paying attention to diseased states of the fluids. But physiology teaches us that the formation of the fluids depends, no less than that of the solids, on certain preceding ac- tions, and that the disturbance of these actions is often known to be, and may probably always be, antecedent to the diseased condition of the fluid parts. In some circumstances the blood is seen to be so suddenly deprived of its vitality, that the pri- mary impairment of that vitality in other cases where there is a long series of morbid phenomena, becomes exceedingly probable. When death is occasioned by lightning, by a violent blow, or by the poison of a rattle-snake, and sometimes even by the unknown poison which produces a sudden and violent attack of fever, in which the patient dies without re-action; the most palpable disorder is effected in the blood itself, which is found to be deprived of its natural and vital properties. The change in these cases is so instantaneous, that even if we admit an antecedent change in the nervous actions, we admit what we are at least unable to demonstrate. Recent observations have made it highly probable that in a severe attack of the spasmodic cholera, the serum and some of the saline constituents of the blood are forcibly sepa- rated from the red globules. In the instance of melanosis, some pathologists have considered the black formation to be a depo- sit from the blood, which has previously under- gone some peculiar change. The growth of po- lypi may perhaps be attributed to some change by which the fibrine is separated from the blood. In other cases, where the duration of less vio- lent phenomena is more prolonged, as in the case of eruptive fevers, we have every proof of the action of the first cause of the disease upon the fluids. In the small-pox we are enabled to com- municate the disease directly through the blood to the whole system. The great respectability of the authorities which might be ranged on one hand as supporters of the doctrine of fever being produced by an atmo- spheric poison acting upon the blood ;—and, on the other hand, as supporters of the doctrine which, admitting the sanguineous changes and their consequences, assert the primary action of the febrile poison on the nervous system;—very forcibly shows the difficulty of determining the question by observation, and in the present state of physiology, of unravelling the intricate impli- cations of the nervous and vascular systems in the performance of healthy, and consequently of dis- eased actions. Any one acquainted with the present state of medical science, and possessed of »ome share of ingenuity, might construct a plau- sible theory by attaching himself to either one or the other of these great systems. The more pal- pable indications of disorder, although that disor- der is often but re-action, would probably cause the number of those espousing the vascular theory to be the most considerable; whilst the undefined limits of nervous influence would give to the nervous theory all the advantages to be derived from bold and unrestrained conjecture. In the mean time, a true and permanent doctrine would still be eventually found to lie between these extremes, and to be founded on the triple basis of cotemporaneous disorders of both the great sys- tems, and on the occasional primary affection of either one or the other. At no period since the first cultivation of medi- cine have physicians ever been so free from any predominant and absorbing theory of diseases us at the present time. So great, indeed, has been the zeal with which facts and cases have been collected, that the age is somewhat open to the reproach of having reasoned upon them too little. Yet, when it is considered how indispensable to a correct system of pathology is a previous enlargement of certain parts of physiological science, it ought to be matter of praise rather than of censure that the. physicians of the present day so much abstain from premature conclusions. When the physiologist can explain the formation of the several secretions from the blood, and the workings of the fine apparatus by which these formations are effected, and new parts formed, while old parts are carried away;—when the rela- tive dependences of the nervous and the vascular systems are determined, and the chemistry of the animal fluids in disease as well known as is that of their normal state, then, and then only, will the doctrine of the intimate nature of diseases become exact. One or two of the general theories of disease, however, which have been prevalent since the commencement even of the present century, may be alluded to. A great majority of the patholo- gists of this country, who ascribe disease to disor- dered actions, for a time adopted the views of the late Dr. Parry, of Bath. He was a physician of great talents and great industry. Amidst the fatigues of a large practice, and many interrup- tions from ill health, he found time to make ob- servations upon almost every form in which disease presents itself; and he proceeded a considerable way towards forming these observations into a great system. Perceiving the error of the older practitioners, who, in their attention to nervous phenomena, overlooked their frequent dependence on vascular disturbance, he rejected, most certainly in terms too positive and unqualified, all idea of a nervous theory, and looked for the origin of almost all diseases to some irregularity in the powers which move the blood. This theory was actually applicable to so many and such severe affections, not a few of which had been previously misunder- stood and very erroneously treated in practice,— and it was moreover so specious and so conve- nient, that it promised fair at one time to be uni- versally adopted. There were few forms of disor- der in which it seemed very difficult to admit, either that the impetus of the blood in the organs chiefly affected was morbidly increased, or, without general disturbance of the circulation, the tonicity of the arteries proceeding to such organs was diminished, their elasticity preponderant, and their resistance to the usual momentum of the current of blood morbidly decreased. In either of these cases, one of which was often capable of demon- stration, whilst the other always admitted of sup- position, and not unfrequently existed, the morbid phenomena present in each case were ascribed to undue determination of blood. DISEASE. 6S1 Of many diseases the first palpable phenomena are affections of the vascular system. But that there are morbid actions in which, even when visibly increased or disordered vascular action is present, it is but an accompaniment, however in- convenient and even hurtful, is sufficiently evi- j dent. The mere disorder in the circulation will I not account for the various morbid processes inci- dental to the scrofulous constitution, or for many I of the affections of the digestive, respiratory, men- tal, and other functions. With all our respect for Dr. Parry, and there are few authors for whom we entertain a respect more sincere, it is impossi- ble to go along with him, when, as if to show his theory in the most advantageous point of view imaginable, he speaks of «that increased determi- nation of blood to the lower extremities which constitutes gout." (Elements of Pathology and Therapeutics, cccclvi.) We cannot, in short, possibly exclude the idea of a peculiar constitution of nervous substance, or modification of nervous action, although such con- stitution and modification are only perceived by certain effects for which no other satisfactory cause can be assigned. If such a pathology be still imperfect, it is only so because physiology is circumscribed. When the nature of that nervous power or influence is understood, which in one part of the nervous substance effects motions in other structures, in another part permits sensation, in another volition, in another the internal sense which governs some of the most important animal processes, and in another all that we call intelli- gence, then may the pathologist presume to hold a bolder language, for he will then advance to facts , with which he is at present quite unfurnished and unaided. In the mean time, the pathological connection between the two great systems, of which illustra- tions have bpen already given, are even now not . neglected in practice. The relief of some nervous disorders is attempted, and often effected, by means acting primarily on the vascular ; as in the case of hysteria, in which venesection is so fre- quently more serviceable than any of the means which are considered to act immediately on the nerves. There are cases of inflammatory disorder in which the best auxiliaries of blood-letting are sedatives, which seem simultaneously to allay nervous and vascular irritation. Attempts are alternately made to check the progress of morbid formations, as of scirrhus, by lessening the supply of blood to the part affected, and by soothing the nervous system. In phthisis pulmonalis, we en- deavour to decrease the general momentum of the blood, or the irritability of the heart and arteries, without repeatedly lessening the general quantity of the blood ; and the means employed, as, for instance, the digitalis or the hydrocyanic acid, seem to act on the whole vascular system by first acting on the whole nervous system. These are so many exemplifications of a liberal and philoso- phical theory of diseases, which, without being formally avowed, appears to us to have been acted upon for many years past, in this country, in a variety of disorders. It is not unpleasing to ob- serve with how little pomp such a system has gradually spread its rational influence over British practice; its unpretending character arising ap- Voi. I. —86 parently from its being little more than a reflec- tion of undeniable facts. The strong disposition of the human mind to rest and generalize after the fatigue of acquiring or observing a limited number of facts, has evert divided into at least two sects those who ascribe disease to disordered actions; and these,adopting a nervous or a vascular theory, are only distin- guished by the particular position they have se- lected, by the particular facts or phenomena on which they take their stand, and which they be- lieve in every case of disease to precede all the rest. A few, and but a few, of the distinguished teachers on the continent yet cling to the assertion that all disordered actions must be preceded by organic or structural change; an assertion imply- ing too complete a reversal of the order of observ- able phenomena to require any discussion. But a much larger sect is composed of those who as- cribe all morbid phenomena, all disease, all struc- tural change or new formation, all disordered action, to some shade or other of inflammation; rather, it is to be apprehended, from a misapplica- tion of language, and the too licentious extension of the term inflammation, than from a real and unqualified proselytism to so sweeping and tin- philosophical a generalization. Another sect, the followers of M. Broussais, whose talents, unbound- ed confidence in himself, and vehement eloquence, have attracted some and scared others to swell the number of his disciples, acknowledge no other origin of the most remote diseases than disordered action, irritation, or sub-inflammation of the mu- cous lining of the intestinal canal; a plausible doctrine, resting on numerous facts, and largely intermingled with truth, but which becomes use- less or unsafe when it is made universal. But whilst almost all the schools of Europe, and we may add of America, have been distin- guished by a calm and philosophical spirit, averse to mere hypothesis, and little addicted to implicit adoption of the tenets of any single master—nul- lius uddictus jurare in verba magistri,—a sect has arisen in Germany, chiefly consisting of men whose enthusiasm far outruns their powers either of observation or of reasoning, and embodied un- der the appellation of Homceopathists. To omit all notice of this sect might be considered impro- per in so general an article as the present; yet to speak of their opinions and practice without de- parting from the ordinary style of medical discus- sion is somewhat difficult. Not without the credit of having pointed out some unnoticed circumstances connected with the administration and effects of medicines, and even deserving of some praise for having enforced a few salutary maxims of diet and of regimen ; the founder of this sect, Dr. Samuel Hahnemann, sur- passes all the heads of all the sects that ever flourished, or that have been forgotten, in the boldness of his assertions, the careless extrava- gance of his deductions, and the scorn with which he regards all whom he fails to persuade. According to the doctrine thus presented to the hitherto deluded followers of physic, the art of curing diseases consists of the employment of me- dicines in each ease, which, in a person in good health, would produce a similar disease. There is, we think, an ancient proverb which comprehends 682 DISEASE. the grand principle of homoopathie, " what will cause a fever will cure a fever ;" a doctrine which appears, at first sight, hardly more reasonable than if one were to say, what will make a man drunk wifl make a man sober ; or, what will break a man's leg will set it. Although, as is the case with any assumed general principle, a few specious fads may be quoted in support of it, or its truth may be admitted in a very limited number of in- stances, no one who reflects on the methods now, by universal consent, adopted in the treatment of the large and important classes of febrile and acute inflammatory disorders, can fail to perceive that a principle from which these and all surgical dis- eases must be excluded, has no claim to be looked upon as general. It can be no matter of surprise that a mind which can calmly entertain such a delusion, should believe that medicines daily used with the effects desired in using them would be more useful, nay, more energetic, if employed in doses a million, a trillion, or a decillion times more minute. Even of this extraordinary dimi- nution of dose, and of ite good effects, some ex- amples may be adduced, which all must admit— that of mineral waters, for instance, although we are not sure that Hahnemann has availed himself of it. But, in this case, small doses are useful where larger doses of the ingredients of the water would be positively hurtful; and there is some- thing, too, in the chemistry of nature not yet per- fectly imitated by art. In many of the cases ap- pealed to by the homoiipathist, (mercury, henbane, &c being employed,) larger doses are given daily and with the best consequences, and in the same description of cases in which the followers of Hahnemann would divide a single dose into por- tions sufficiently numerous for all the patients in all the hospitals in the world. Still the narrow principle is again admitted, as universal, unde- niable, and now first revealed to mankind. Pre- cisely the same kind of reasoning pervades the homoopathie doctrine of chronic diseases, all of which are ascribed to syphilitic taints or to some form of cutaneous disorder: thus adding another to a thousand previous instances, that in the cir- cle of diseased actions any separate portion may be fixed on as the universal beginning by those whose defective sight is confined to that portion. The reception of such doctrines, even by a few individuals, in any country where the reasoning powers are not utterly neglected, can but be re- garded, to use an expression which the late Dr. James Gregory used to apply to such follies, as a pitiable proof of the ignorance and credulity of mankind. No one will think such censure un- justly applied to Homoiipathists, if he recollects, that without disputing concerning the examples which they bring to support their great principle of curing by resemblances, its absolute admission would dictate that ardent spirits should be given in phrenitis, in gastritis, and in cystitis ; opium in lethargy and coma ; turpentine in irritable states of the urethra, and aloes in painful hemor- rhoids; and that the only defence to be made against the accusation of merciless and even fatal practice in such cases, rests on the tenfold greater, although less dangerous, folly of giving the ardent spirits in doses of five hundred parts of a drop, and the turpentine and aloes in doses of the mil- lionth part of a grain. Relations and Conversions of Diseases. —Dismissing the subject of general theories of disease, it belongs to the general view of the laws which govern morbid actions, to notice the singular relations which exist between affections of differ- ent parts of the body, and also the conversions of diseases which are sometimes found to occur. These may be viewed in connection with the vascular or the nervous system. The relation and conversion of diseases dependent on a state of plethora are so commonly observed as to be known to all practitioners. Such a condition not only disposes to all inflammatory disorders, but may induce the especial embarrassment of any single organ without inflammation ; as, in the lungs, asthma or pulmonary apoplexy ; in the brain, le- thargy or cerebral apoplexy. Combined with a predisposition or susceptibility of the nervous sys- tem, it may concur to the production of gout'or of mania. As regards the relation of affections of the ner- vous system, we see whole families—every mem- ber exhibiting the family susceptibility, but each in a different manner, either from different por- tions of the nervous system in each being inade- quate to healthy actions, or peculiarly affected by the circulating system. Eccentricity, excessive shyness or timidity leading to seclusion, chorea, epilepsy, amaurosis, mania, and other nervous affections, are very commonly observed thus asso- ciated by the bonds of relationship, giving as dis- tinct a character to large families as the most peculiar external features of resemblance trans- mitted by inheritance. New directions given to certain portions of the blood, together, probably, with a transference of morbid actions in the nerves, may cause not only the conversion of gout to mania, already mention- ed, but of erysipelas of the scalp to phrenitis, or of erysipelas of the trunk to sub-inflammation of the intestinal coat with diarrhcea. The sudden repulsion of some of the disorders of the scalp in children, as of porrigo, is not unfrequently follow- ed by meningitis. The sudden recession of the cutaneous efflorescence and inflammation in ru- beola, scarlatina, or variola, is commonly followed by inflammation of the lungs, or the bowels, or the brain. The supervention of an affection of a new organ, or the subsidence of a similar disorder of an organ primarily affected, is usually termed metastatis,- among the most familiar examples which may be mentioned, is that of rheumatism, in which the articular affection, when it suddenly ceases, is not unfrequently followed by inflamma- tion of the pericardium, and even of the heart itself. Irritations of the nervous system, of which the actual nature is very obscure, but the effects are very serious, may now and then be observed to succeed each other either by natural conversion, or in consequence of means employed for the cure of that which first existed. The most strikiiv case of this kind which we ourselves have wit- nessed was that of a lady, who had been for several years affected with melancholia without any discoverable cause. When all the resources DISEASE of ordinary means and medicine had been un^ avaihngly exhausted, she 683 ovaumgiv exnausteu, she was persuaded to try the prescriptions of an irregular practitioner. By his advice she persevered for some time in the use of the corrosive sublimate, together with large - doses of the sulphuric acid. The mental depres- ' sion gave way whilst she was taking these medi- cines, somewhat, as may be supposed, to the dis- comfiture of those who had vainly attempted to produce the same good effect. In a very short time the same patient began to complain of pain referred to the back and loins, of a burning cha- '■ racter, at first occasional and not very severe, but which gradually became heightened to the extreme of human agony. Medical and surgical skill were fruitlessly exerted even to give temporary relief, j and no means seemed for a moment to suspend | the malady, or to give the faintest hope even that the principle of transition or conversion could be brought into operation for the patient's benefit. Her sufferings were unintermitting, except during short and broken intervals of sleep, for nearly two years: the lower extremities became powerless, then contracted, then inflamed by contact; and! these complicated afflictions only ended in death. | The most singular transitions of nervous irrita- tion are exhibited in hysteria, in the course of | which the most severe inflammatory affections are sometimes simulated in succession. | The inconveniences following the removal or I cure of chronic diseases are often such as to make the propriety of endeavouring to put an end to J them somewhat doubtful. After the cure of a chronic diarrhoea by metallic astringents, we have noticed the re-appearance of scrofulous ulceration of the skin ; and in a case in which this had oc- curred, and the ulceration was healed by a despe- rate quack, symptoms indicative of pulmonary tubercles immediately appeared, and death ensued. The same phenomena have often been known to follow measures calculated to repel enlargements of the cervical glands. We have many times observed the supervention of various inconve- niences on the disappearance of chronic or habitual coughs. The cessation of gout, or the suspension of hemorrhoids, has often been followed by epilepsy or by asthma. These accidents, of which a long list might be given, prompt a very important indi- cation to be observed in the treatment of all such affections, which will be dwelt upon in the article Medicine, Practical, Principles op. Occasionally there is a translation of diseased exhalations or effusions. Anasarca will subside, mid oedema of the lungs will follow. Hydrothorax or ascites arc sometimes much relieved by dropsical swellings occurring in the extremities. General dropsy has come on after the cure of ephidrosis, both affections seeming frequently to be meant for the relief of plethora. Some affections are suspended during pregnancy, apparently in consequence of a converted determi- nation from the part disordered to the uterus. The instance of phthisis has frequently been observed ; and we have noticed remarkable examples of it in obstinate and extensive psoriasis. It is curious that the determination to the raamnue during lactation does not prolong the benefit; a fact which common observation confirms as regards consumption, and which we have equally noticed in the example of cutaneous disease. The object of the law of nature here exemplified seems to be the preservation of the species, which after partu- rition may be vicariously performed. Modification of disease by temperament. — Other modifications of disease arise from what are called temperaments.- they modify the pre- disposition to receive disease from the several causes which have been mentioned; and they modify the course of disease when it is excited by any cause. The term temperament, however, founded on an ancient doctrine of four humours supposed to temper each other, but long employed without reference to the theory in which it arose, and often with a vague and unsettled signification, is among the inconveniences of medical nomen- clature, which so many have prided themselves on deforming by new additions of barbaric jargon, and so few have attempted to purify and improve. The sanguine temperament (indicative of the predominance of the sanguineous system), the choleric (or bilious), the phlegmatic (or pituitous), and the melancholic (or atrabilarious), are desig- nations which, however frequently and familiarly employed, convey little precise meaning, and that little not always correct. The sanguine tempera- ment is supposed to be characterized by a full habit, a soft skin, a ruddy complexion, red or auburn hair (the fiavus of the Romans, and what the Scotch still call yellow-haired), a frequent pulse, large veins, and vivid sensations. The melan- cholic, on the contrary, is described as existing in a firmer frame, and thinner, with a dark skin, black hair, and a slow circulation: the nervous system is less easily moved ; the disposition is grave and meditative (meditabundus, Gregory, in Conspect. cap. xxiii.), and the affections are fervent and steady. Intermediate between these is the choleric. But the phlegmatic differs from all in the laxity of the skin, the paleness of the face, the lighter colour of the hair, and the greater sluggishness of the faculties of the mind. It is unquestionable that this ancient division must have been the product of extensive and deli- cate observation. It is even possible that when the varieties of men were less mixed, the temper- aments, some of which continue the characteris- tics of nations, were less blended. At present, all attempts to limit the inexhaustible varieties of temperament, compounded, it may be, of so few and such simple elements, is as unsuccessful as to comprehend within the bounds of a few de- scriptions all the variety produced by the different associations of the few features of the human face. However interesting, therefore, a recollec- tion of the temperaments may be to him who speculates on the varieties of human character, it now affords little help to the practitioner of medi- cine, and a consideration of their divisions may advantageously give place to one which has the recommendation of being at once more simple, not less comprehensive, and more easily admitting every diversity. There is an evident difference in the suscepti- bility of different individuals to external and in- ternal, to bodily and mental impressions; and this susceptibility, to the expression of which we would in medical language limit the word temperament, may be, and doubtless sometimes is, uniform 684 DISEASE. throughout the whole individual frame of body and mind. But it is so oftpn irregularly disturbed, and so often variously limited in different indivi- duals, so liable also to transitory and permanent increase or diminution from various accidental causes, that it requires, for any useful pathologi- cal or therapeutic end, to be regarded with little or no reference to an arbitrary division admitting only of complete individual varieties. From the original or constitutional excess or defect of sus- ceptibility to one or more, or all the impressions which the mental and bodily frame is intended to feel, arise various diseases, and the diseases affect, for the same reason, a particular course. The susceptibility may be so increased, that common light, common air, common sounds, common food, common occurrences, cannot be tolerated : it may be. so diminished that these circumstances do not affect the senses on which they are intended to act. But the susceptibility may be partial; in- creased at one time, diminished at another—in- creased in one organ, and not in others ; dimin- ished in some organs, and in others increased. To this kind of susceptibility the practitioner is required to pay much attention, in order to dis- cover the tendency in his patients to particular forms of disease, and the consequent propriety of pursuing particular methods of cure. The occur- rence of disease in any organ commonly, for a time, increases or diminishes its susceptibility to ordinary impressions. Thus, after fever, the brain and the intestinal canal occasionally remain for some time irritable and intolerant of all impres- sions, and in other cases for a long time inert and torpid. The disease of some organs induces or is connected with peculiar states of susceptibility in others. During the progress of tubercles in the lun^s, the irritability of the heart is very con- spicuous, and that of the bowels is not unfre- quently fatal. In morbid states of the brain the stomach is sometimes irritable, and vomiting is a symptom ; and sometimes in a state so completely opposite that powerful emetics will not rouse it, and food is obstinately refused. In the same indi- vidual we may see the mind excited, or exhibit- ing, if we revert to the old terms, the peculiarities of the sanguine temperament, and the stomach, bowels, and skin decidedly phlegmatic; and to such cases no general term can correctly be ap- plied. All these varieties of susceptibility under- go modification by climate, by diet, by excessive evacuations, by the neglect of exercise, by exclu- sion from pure air, by mistaken habits as regards clothing, and by other causes of which the im- portance is fully shown in the article Eitcation, Physical, to which the reader is referred for many particulars which could not properly be here introduced. Modifications, both as respects the whole body and particular parts, are effected by age, and are noticed in the article under that head already referred to. Generally speaking, there exists in women a greater degree of susceptibility to impressions than in men; and this is very often observed in that degree of excess which constitutes what Dr. Cul- len called mobility, and which is the affliction of the greater number of those who are termed ner- vous patients. These are the individuals who feel all the impressions of sense with almost pain- | ful acuteness : they long retain, and vividly recal, I the impressions of music and of painting, except when new objects excite them, and therefore long- J est in the dark ; and they are prone to hysterical affections, as various as the sensations and actions can be which may be associated with morbid con- ditions of all the various parts of the nervous sys- tem. (See Hysteria.) The importance of be- ing acquainted with the modifications of disease in a temperament of this kind is very great in- ! deed. Such patients are not only more readily I affected by disease, but by remedies, than other ' patients. Soon reduced to apparent weakness, | the same facility of being acted upon by various ; stimuli occasions their recoveries to be often equal- I ly sudden, and to the inexperienced practitioner surprising. Both the prognosis and the treatment must be regulated by these circumstances. Vio- lent medicines will do the patient harm and him discredit. The pale, languid, feverish, irritable, complaining patient of to-day may before to-mor- row be converted, by the unexpected visit of a friend, into a patient no longer submissive to phy- j sic, or mindful of slight ailments, but anxious to | return to all the amusements of a dissipated life. I In proportion as there is in the male sex an ap- proach to this mutable susceptibility, the practi- tioner must expect the same results, and observe I the same caution. Vis medicatrix.—The signification and value of the different symptoms and signs of diseases are treated of in the articles Prognosis and Symptomatology. There is, however, one view of symptoms in general which especially belongs to the general subject of disease; namely, their frequent indication of that power in the system to which has been given the appellation of a via medicatrix naturx. This curative power or pro- perty, although the idea of it may have been push- ! ed needlessly far, and rendered somewhat too ' material, is an undoubtedly existing property of the living animal body. It is this which Van Helmont personified as the archseus, or grand re- gulator, whose throne was the stomach. It is what Wepfer called the president of the nervous system .- and we do not see that Stahl went be- yond them when he referred the government of the body » directly and entirely to the rational soul," diffused, however, over the whole body.* The truth is, that we have daily proofs of there being a power in the constitution to repair injuries and restore lost parts; and that several actions which we call disease are instituted to get rid of the causes producing them. Nor is there any necessary extravagance in the supposition that the possible intention of all may be so. The law may, perhaps, be said to be analogous with, or con- formable to, the law of which natural philosophers have gained a knowledge by induction from vari- ous phenomena ; that all action is followed by re- action, equal to, but different from, the primary action. If a bone is broken, if a muscle or tendon, or even a nerve is divided, the divided ends are re- united. If a portion of substance, as of the skin and cellular membrane and muscle, is lost, or cut * See Hoffman, Commenlarius de differentia inter HoflT- inanui doctrinain medico mechanicam et G. E. Stahlii nicdico-organicam. DISEASE, 685 out the deficiency is repaired, and the cavity built up by granulations from the bottom, and at last covered m by new skin. If a part removed is without much delay re-applied —a tooth, the tip of the ear, a finger, a part of the nose—it becomes firmly united in its original situation. So anxious, if we may so speak, is nature to preserve, the life she has given, that wounds of the most important organs will cicatrise ; wounds of the lungs, of the heart, of the intestines, of the bladder, of the ute- rus, even of the brain. Dr. Parry enumerates among salutary processes, re-action, shivering, convulsions, bodily exercise, tears, sighing, gout, dyspepsia, formicatio, vertigo, coruscations, fever, loss of appetite, and wasting. The propriety of including some of these may ap- pear questionable; but illustrations of the salutary effects of the greater number will so readily pre- sent themselves to those familiar with pathological phenomena as to require no further observation. Many cases of conversion of disease are, of course, to be referred to the same head.* Viewing the principle in its widest extent, it may be said to be first exemplified in the convulsions of infancy ; and it is exhibited for the last time, and ineffec- tually, in the convulsions so often preceding death. There is a kind of consolation, not unattended with a hope of the final extension of medicine far beyond its present powers, to be derived from ob- serving that even diseases of a most fatal character evince a conformity, as it were, to the same great curative and preservative law. The whole series of changes in the tubercle are but so many efforts to dislodge and eliminate it from the lungs; the process is attended with irritation, and by long continuance, or rather by constant repetition, it generally ends in death. A similar process pre- vails in cancer, and is sometimes, although rarely, more happily effected. Calculi in the bladder occasionally become enveloped in pouches of the lining membrane, and irritate the patient no more ; and sometimes escape by ulceration into the rec- tum or vagina, or through the abdominal integu- ments. There can be no difficulty in admitting these indications of the vis medicatrix naturae, without referring them to anything more than an internal sense, which the preservation of existence did not require to be of the same nature as what are called the external senses. It would be hardly necessary to allude to the more material character given to this power, if the physicians who were most dis- posed to invest it with personal properties and dignity, had not, as a natural consequence, be- come too scrupulous about opposing it, even to the extent of curing all diseases by what the French have called expectation. The proper advantage of acknowledging such a power is, that it prevents indiscriminate and offi- cious meddling—thatmediciria/>er/w&afn'.r which incessantly contradicts even the best efforts to- wards a natural cure. In the modem practice of medicine and surgery, the vis medicatrix naturae is seldom disregarded ; but its suggestions are not followed without discretion. Seeing the in- tention of its working, it is yet often seen by the * See Parry, Elements of Pathology and Therapou- ties vol. i. 1'ar. dc-cclui to dccclxvi. Second edition, 1825. 3h I practitioner to work in a dangerous manner, and I too much by a general rule; sometimes too ab- : ruptly, and sometimes after too lingering a man- | ner. The object of art is to adapt the rule to l particular instances; and the greatest wisdom of | the practitioner is shown in determining when to | wait upon nature, when to rouse her to exertion, | when to moderate those exertions, and when to ! put an absolute stop to them. When a bone is broken, the body being pre- viously in full health, the vis medicatrix naturae is soon in full activity; the whole restorative force j is called out. The vascularity, the heat, the vitality of the surrounding parts is increased; and inflammation ensues. But it is often necessary to moderate this zeal and haste of nature; to lessen the superfluous excitement, leaving only that degree of it without which the repair cannot pro- ceed. Among savages the natural power of heal- ing is so perfectly exercised, that it is said the most frightful wounds will heal without surgical aid. On the other hand, a patient of infirm con- stitution or disordered health becomes subject to some local congestion ; or some accidental and trifling injury brings a part of the integuments into a state of chronic and inactive disease ; and the vis medicatrix naturae is not exerted until the obstacle to its exertion, the disordered state, per- haps, of the digestive organs, is removed by alter- ative medicines : but that done, and a wound or abrasion, which had remained stationary for weeks, instantly puts on a new character; secre- tory and absorbent processes are at once com- menced, and the cure is soon completed. We see, too, in the case of a patient alarmingly lowered by an attack of fever, the nervous energy sunk, the power of the heart diminished, the digestive function almost annihilated, the respira- tion laborious and feeble. Nature, unassisted, will undoubtedly try to make this patient rally: but if the trial is successful, it can only be so in the course of many weeks, perhaps many months ; and the body and the mind will long continue to suffer, or perhaps never wholly recover. Often, after a succession of attempts, the patient sinks at last. But we know that by stimulants and tonics judiciously administered, we can rouse the powers ! of digestion, and re-animate the whole frame, in less than half the time and with less than half the danger. Whilst, however, we seriously consider the design of nature in any malady,—whether she is working, and how she is working, and how the machinery will endure the process she has set up —we should still, having to treat diseases as they occur in civilized life, never trust entirely to the vis medicatrix nature, except in the case of the most trifling injuries, where a process of very small extent is all that is required for the cure. The natural powers of healing and recovery are in many cases strongly influenced by peculiar mental states. The same emotions and passions which redden or blanch the cheek, which affect the cutaneous and renal functions, or those of the stomach and bowels, can also promote or retard the activity of the vis medicatrix naturae. Confi- dence of recovery often conduces to recovery; and extreme despondency concerning the tendency of a disease sometimes leads to a fatal result. This 686 DISEASE. is very conspicuous in some affections, as in fevers; and has often been asserted to prevail in malignant disorders, particularly in cancer: and some practitioners are consequently inclined to place implicit reliance on the prognostics in which their patients are disposed to indulge. But the example of phthisis, which is in that respect not singular among chronic disorders, may serve to show that confidence may be even a part of the disease, arising from a morbid condition of the sensorium : and we have attended patients in lingering forms of fever, which ended happily, yet throughout the whole course of which it was im- possible to excite a ray of hope in the mind of the patient. In some cases the cessation of the fever induces a deep but temporary despondency of recovery. Even with these exceptions, the influ- ence of the mind over disease should never be overlooked by the practitioner; nor should he forget to inculcate that this influence of the mind, like all the mental actions, may by firm endea- vours be to a great extent subjected to the will. Acute and Chronic Diseases.—The differ- ent period required by different disorders, unas- sisted by medicine, for the production of a natural cure, or, in fatal cases, for the destruction of life, has long been the occasion of a general division of diseases into acute and chronic. Acute dis- eases are commonly attended with severe and obvious symptoms; whilst chronic disorders are usually less marked, and attended with less suf- fering. To these distinctions there are, however, exceptions. Diseases of short duration, and in their effects destructive, are sometimes attended with few symptoms of the mischief they are effecting in the brain, in the lungs, or in the intestines; and diseases slow in their progress are often accompanied with sufferings of a very severe kind. In acute disorders there is, except in rare instances, warning sufficient to guide the prac- titioner ; but in chronic diseases the most exten- sive injury sometimes proceeds undiscovered until the discovery is useless. Acute inflammation, for instance, can seldom be overlooked ; but chronic inflammation is frequently unnoticed until some of its worst effects on structure have been wrought by long continuance. It is no less essential to the physicians than to the surgeon to be especially mindful, in all obstinate maladies, of the possibility of serious disorder. Periodicity avd Crtses of Disease.—But there are also diseases, acute as regards their severity, and chronic as regards their duration, which are what is called remittent and intermit- tent. The symptoms arise and decline in a certain series and in a certain time ; then disappear, and after a certain interval are renewed. The class of fevers remarkably exhibits all the peculiarities of remission and intermission; and these will be described under the head of Fever. In this geneial view it may be sufficient to mention, that in our common continued fevers there is generally once, and sometimes twice, in the space of twenty- four hours, an observable remission or marked alleviation of the febrile symptoms. It is, however, in many cases not very striking; and it is always less striking in this country than in tho.-;e fevers of wanner climates to which the observers have agreed to give the name of remittents. In one class of fevers, sufficiently familiar to the prac- tioners of marshy countries, the remission is so marked and of such continuance as to be denomi- nated an intermission. Each paroxysm of an intermitting fever or ague has a precise beginning, middle, and end, with an unquestionable cessation for a time, after which a new paroxysm is com- menced. The intermission is never of less length than some hours ; it is often twenty-four, and not unfrequently forty-eight. Not, however, in fevers alone have these well- known but unexplained circumstances of inter- mission and remission been observed ; diurnal remissions are distinguishable in every attack of inflammation. There are periods of the day or night in which the symptoms are less severe, and other periods in which there is an exacerbation. Even some inflammatory affections are intermit- tent, of which, perhaps, rheumatism is the most frequent example; although pleuritic and other inflammations have been described as assuming the same character. An intermittent form of attack may very com- monly be observed in many of the disorders usu- ally called nervous or spasmodic; as in hysteria, epilepsy, and nervous asthma. Close observation will occasionally detect regularity in the attacks of epilepsy, where slight inquiry would not cause it to be suspected. We have sometimes found the alternate fits corresponding in point of time, and the paroxysms very nearly observing two distinct periods; so as to be somewhat analogous, only with much longer intermissions, to what is called a double tertian. The same intermission, more or less regular, and often with considerable inter- vals, prevails in a great number of cases of mani- acal affection. The intermissions in these instances appear sometimes to be associated with periodical changes, not appreciable except in their effects, in the ner- vous system itself. At other times there is a manifest periodical excitement of the vascular sys- tem ; but whether a primary excitement or not, the progress of physiological and pathological knowledge will alone discover. The ancient cul- tivators of medicine attached considerable impor- tance to the periodicity of inflammatory affections, even of the slightest kind ; believing that what- ever measures were employed, they would run a certain course, mitigated perhaps, but not prema- turely brought to a termination. Both with respect to these and to the febrile disorders, certain days were believed more favourable to a termination of the malady than others, or even to its amelioration. These were called critical days. If the disorder did not begin to decline, or altogether decline, on one of those days, the hope of the practitioner was transferred to a future critical day, overleaping one or two days, and sometimes a greater number. Unfavourable changes were alleged to occur on the same days in bad cases. For a belief sanc- tioned by the acute observation of the Greeks, and more or less cherished by almost every sect up to the present day, it must at least be said that there must be some strong foundation. Yet on few points are modern authorities more at variance ; some retaining the old faith pure and unmixed; some admitting it with reservations; and some DISEASE. 687 .regarding it as a venerable but a groundless pre- judice. We are not afraid to confess that our in- dividual observation inclines us to rank among the behevers ; although at the same time we acknow- ledge the insufficiency of individual observation on a question of this nature. There is some analogy between these periodic movements of disease, and the periodical perform- ance of certain of the healthy functions, although, as regards several of the latter, the effect is com- monly ascribed to habit. The desire for food, how- ever, and that for sleep, which may be looked upon as indications of an approach to a state of ex- haustion in some part of the system, are found to recur within a certain period in all; whilst in the instance of the uterine functions in the female, and in the frequent examples of inconveniences resulting from a plethoric state of the blood-ves- sels, there is a certain effect produced within a given and exact time, and with which habit can have nothing to do. Again, in almost all slight but not very transient disorders, there is an alter- nation of excitement and depression, " a good day and a bad day ;" and, during convalescence, par- ticularly from fever, we have often noticed the great distinctness of this intermittent or periodical character. As from the earliest cultivation of medicine it was observed that some peculiar circumstance or state of the body accompanied the solution of many diseases, or preceded and, as it were, an- nounced their favourable issue, or, on the other hand, their termination in death ; these circum- stances or states came to be spoken of as consti- tuting what was called a crisis, (from icplo-ic, judg- ment,) and the days on which they were most generally found to take place were termed critical days. This language still prevails, even among those who are less inclined than ourselves to credit the ordinary restriction of such occurrences to dis- tinct periods. Certain changes, often noticed as preceding death, more especially in chronic diseases,—hic- cup for instance,—and which are therefore consi- dered and called critical, do also, if any faith may be reposed in popular observation, sometimes recur, increase, or alternate with other critical changes, at periods answering to that when the first warn- ing of that kind appeared. If physicians place no reliance on such testimony, we are inclined partly to attribute it to their being seldom long engaged in watching maladies at the bed-side, where the senses and thoughts naturally become concentrated on the events of the sick chamber alone. Our own observation in the course of country practice, and in cases where circumstances have occasioned our attendance to be close and protracted, has, we must candidly own, gone some way to corroborate the popular evidence on these points, which are certainly not of a nature to be made familiar to those whose chief knowledge of disease is acquired in formal consultations, or in daily visits to the wards of public institutions. No harm can arise, at all events, from directing the practitioner's attention to a subject which can only be investigated by a close attention to ad the phenomena of ordinary sickness. In the progress of a fever, the recovery or the fatal termination is doubtless often preceded by some new action exemplified in the state of the bowels o>- of the skin. The sweating stage of an intermittent will occur to every reader as an ex- ample ; but analogous phenomena often charac- terise those fevers which are denominated con- tinued. Some are also distinguished by critical eruptions, of which the appearance relieves the febrile state. Certain conditions of the cutaneous or respiratory functions, productive of a peculiar odour of the breath or perspiration, are well known to practitioners as indicative of an aggravated malady. Inflammatory disorders sometimes suddenly and happily terminate on the supervention of cathar- sis ; whilst the common termination of inflamma- tion in abscess is itself often spoken of as critical; so that to this day we hear of crude abscesses, of the digestion of the pus, and, among the older members of the profession, of the coction of the matter. Nervous affections, dependent probably in such cases on a plethoric state of portions of the nervous system, often for a time disappear im- mediately after an attack of epistaxis, or, in fe- males, on the appearance of the catamenia after suppression. The accession and the departure of a paroxysm of hysteria or of asthma is sometimes marked by a copious flow of limpid urine; and a very free excretion of mucus from the bronchial membrane forms the common and true crisis of the asthmatic fit. Countless illustrations might be accumulated, but no one conversant with dis- ease can have failed to remark them. According to doctrines now very little regarded, these and numerous other phenomena acquired an additional importance from being considered in- dicative of the successful or unsuccessful results I of a supposed struggle in the system for the ex- pulsion of a morbific matter; a supposition which, in many cases, is so far from being in any degree unphilosophical, that it rests on facts too plain and of too frequent occurrence to admit of the least dispute. The terms crudity, digestion, arid coction, have however been conveniently laid aside, as communicative of a sense which was not suffi- ciently exact. The days on which the critical events are to be expected, have been variously named by different observers. This discrepancy, and, indeed, the chief difficulty in ascertaining, by actual observa- tion at the bed-side, the truth or incorrectness of the ancient belief, arise from the same cause, namely, the uncertainty so often existing respecting the day on which any given disease actually com- menced. In fevers, the first day is sometimes suf- ficiently marked, but not uncommonly it is impos- sible to determine when the general disorder was really advanced to the febrile condition. We should ourselves venture to direct the attention of those anxious to investigate this curious subject, to the third, fifth, seventh, eleventh, fourteenth, and twentieth days of our common fevers; and we think their attention will not go quite unre- warded. The physician will, perhaps, find that in a con- siderable proportion of cases of continued fever, his services are first deemed necessary on the third day of fever, in consequence of symptoms indica- tive of a serious disorder then first becoming ob- servable to the friends of the patient. Judicious 688 DISEASE. treatment will often assist in bringing about a favourable change on the fifth or seventh; or a decided improvement will occur between the elev- enth and the fourteenth day ; or be postponed until about the twentieth. Without affecting rigid exactness in respect to these days, or attaching extravagant importance to them, we have certainly thought ourselves justified in these conclusions respecting them, by observations made in circum- stances not unfavourable to precise and undis- turbed observation. The principle assumed is one which in numerous cases of disease is perfectly undeniable—that certain morbid processes are for the most part effected in definite periods of time. It is not the object of the present work to col- lect the curiosities of medical literature; and we have therefore briefly dismissed this, among other subjects, on which it would be easy to prolong ingenious discussion. The practical application of the doctrine of a crisis is obvious. Its observa- tion may conduce to exact prognosis; an art so difficult and deceptious, that all prudent physi- cians advise that the prognostic should be guard- ed with a care that may, in all cases, cause it " to quadrate with the event;" but at the same time an art in which the observant practitioner won- derfully excels those whose notice of the turns and changes of maladies is less diligent. Moreover, if a disease ordinarily terminates in some specific way, or in some specific crisis, the induction of that particular crisis becomes a wise indication for the guidance of the practitioner, although it will often be found that art cannot accomplish more than an ineffectual imitation of those critical evo- lutions which nature wants the power to perform. Besides the property inherent in the body which may be assumed in many instances of periodicity to be the primary cause, there is an evident pe- riodical influence exerted over many maladies by certain combinations of temperature, moisture, electricity, and other atmospherical properties, at different seasons of the year. There are indivi- duals who in the spring of each year become maniacal; others in whom the heat of the sum- mer seems to produce the same unhappy effect, and who are well in the winter. A tendency to vernal fever is very common in delicate women ; and an aggravated dyspepsia, arising from gastric and intestinal irritation, is the frequent precursor, and apparently the exciting cause of many of the fevers of autumn, which are so commonly termed bilious; and with which some individuals arc re- gularly attacked every year. The influence of the heavenly bodies on the corporeal actions of the beings inhabiting this planet, the lunar and sol-lunar influences, once so reverently regarded, have been for some time past so often the subject of ridicule, as to make almost any allusion to them liable to the same reception. It would, however, be difficult to show, in the first place, any very good reason why ani- mal bodies should be exempted from the operation of masses capable of acting on large portions, or on the whole of the globe on whieh they live ; and abundant testimony, although not always, it must be confessed, very conclusive, might be col- lected in favour of views which h.ive been too entirely discarded. That a lunatic should be un- der lunar influences, is an opinion now seldom mentioned but to afford an opportunity for com- placently contrasting the wisdom of the present time with the credulity of the past. Yet of those who have the charge of lunatics we have, we think, found the majority disposed to believe as their forefathers did. The determination of all questions of this kind requires such long and pa- tient observation; there are so many collateral sources of deception, and the exceptions appear to be so frequent; that it is to be feared mankind will long continue to content themselves with un weighed assertions on the one hand, and indo- lent and contemptuous incredulity on the other. Nosology.— It was our intention to conclude this article with a view of the different arrange- ments of diseases which had been made by suc- cessive physicians since Araetcus first divided them into acute and chronic, unless, as is some- ■ times stated, Asclepiades is to be considered as having been the first deviser of nosology, many of his definitions being retained by Caelius Aure- lianus. Galen, however, mentions Mnesitheus, who lived after Hippocrates, as having distin- guished himself by the classification of maladies. Conceding that the use of all nosological studies is really limited to the schools, and that to the practitioner they afford no immediate aid, it is yet not uninteresting to see the way in which some of the greatest men who have ever cultivated physic have attempted to reduce the innumerable diversities of disease into something like order. Not to dwell on their divisions into those of the solids and fluids; into internal and external; into idiopathic and sympathetic ; into protopathic and deuteropathic; into hereditary, congenital, and acquired ; into those of infancy, childhood, adult, and old age ; into those attacking men and wo- men ; into the salutary, the benign, the malignant, and the pernicious : and without insisting vehe- mently on the importance of the divisions into curable, incurable, and fatal; or, with regard to ' the seasons, into the vernal, those of summer, the autumnal, and those of winter; or into the spo- radic and popular ; or into febrile and non-febrile; or sthenic, or asthenic; or general and local : and passing over many other refinements of a like kind, too often based on erroneous theories; — it would be most unjust to forget the eminent ser- vices of Sauvages, the first of the modern nosolo- gists, (1731,) and the frequent references to whose writings in this work sufficiently show the estimation in which he is yet held. The celebrated Linnaeus also, in 1763, endeavoured to arrange diseases with the same regularity with which he classed the objects of botany, but with less suc- cess. Among the classes of Sauvages were anno- tations, weakness, pains, and discharges, all of which are usually but the effects of disease. In the arrangement of Linnaeus, fevers and syphilis are placed together, on the ground that both are contagious. In the more complete attempt of Dr. Cullen, praised, and justly praised, as an estimable work by his successor, Dr. Gregory, catarrh and dysen- , tery are placed together, because both are pro- fluvia, or discharges. Dr. Cullen's nosological arrangement was succeeded by that of M. Pinel which became as general in the French schools l as that of Cullen had been in England. The DISEASE. 689 arrangements of Sagar, Macbride, Bang, Daniel, J. P. Frank, Sprengel, Hufeland, and many others, in whatever estimation they were once held, or whatever merit they possess, are now seldom re- ferred to except by the curious. Even Cullen's nosology is almost unknown in the schools of London ; and Swediaur, who tried to improve it, is no better remembered. Among the nosologists who have pushed the science to extremes, Vitet is sometimes alluded to, as placing in his sixth class, or diseases of evacuation, and in ite fourth order, of organised bodies, accouchement, avortement— making pregnancy a disease, "beginning in con- ception, and ending in delivery." The name of the celebrated John Brown de- mands, at least, a passing attention. Dividing all disorders into sthenic and asthenic, he established on that bold foundation a superstructure of physic so ingenious, that, great as its defects were, and great the practical errors into which they led, they long attracted the regards and admiration of many of the most farpous schools of Europe. With more attention to the natural phenomena of the human body, with more practical experience and wisdom, but at the same time with a freer indulgence of fancy, Darwin attempted a new arrangement of diseases in the Zoonomia; a work in which, amidst a great variety of matter of very various value, the student will find many practi- cal observations indicative of the penetration and genius of its distinguished author.' Dr. Bartholomew Parr, the author of the Lon- don Medical Dictionary, a work of great merit, and full of practical information, attempted to improve the nosology of Cullen, but little was gained by the attempt. Inflammations constitute his second class, and in it we find phthisis. In the profluvia we meet with cholera and diabetes. In the suppressorii, or suppressed functions, we find constipation, and asthma, and jaundice, and thirst. These obvious inconveniences of artificial clas- sification, which so many able persons have been so little able to avoid, show in an unanswerable manner the inutility of such divisions. If we were disposed to ridicule the science of nosology altogether, we might dwell on the nosology of Dr. Parkinson, who divided all diseases into hyperbio- sis and catobiosis, and hoped " to obliterate the term fever from nosological language;" or we might turn to the cliemical nosology of M. Baumes, of Montpellier, who classified maladies as calorin- ised, oxygenised, hydrogenised, azotinised, and phosphorenised. But any further consideration of the subject would be of little use to readers of any class. If any arrangement is likely to be useful in a practical point of view, it would seem to be either that of diseases according to the parts, or the functions which they respectively most affect. The former is the arrangement followed by the present professor of the practice of physic in the London University ; and the latter was followed by the writer of this article in the same chair. By observing either of these methods, the stu- dent's practical knowledge seems most likely to become conveniently and usefully arranged, so as to be retained with the greatest certainty, and referred to with the greatest facility; the first inquiry of a practitioner who is investigating the case of a patient, being concerning the part or function affected. Some affections, as fever, being of a general character, are conveniently placed in a distinct class. The specious exactness of an arrangement proposed by Dr. Young, the learned author of the Introduction to Medical Literature, never sufficed to bring into general notice a system which was seen, at the first glance, to be without any practical utility ; and the same general objec- tion may well excuse cur dwelling upon or detail- ing any particular system in a work like the present. The functional arrangement adopted by Dr. Mason Good might deserve particular notice, on account of the reputation of its author, were it not that his incredible prodigality of barbarous medical terms has made his nosological arrange- ment, if not quite confused and unintelligible, at least such as to defy the efforts of the strongest and most retentive memory. Having ourselves attempted a plan much less ambitious, and, as we believe, much more useful, it affords us no small gratification to find that the principle of that | which is followed by a teacher of so high and deserved a reputation as Dr. Elliotson, is as nearly as possible the same. The only object of any | consequence which it was ever pretended that | nosology could effect, is the accurate discrimina- tion of diseases. This cannot be taught by short definitions, but by full, and careful, and collated descriptions : and in order that such descriptions may be readily made and remembered, we believe that arrangement of diseases to be the best which causes those which affect the same organ to be brought close together. Their resemblances may thus be best compared, and their differences best observed ; of which the result will be, that facility and accuracy of diagnosis which so greatly con- tribute to distinguish one practitioner from another ; and, indeed, without which, no man, be his learning or his science what they may, can ever practise physic with success or satisfaction. J. Conolly. [DISINFECTANT; from dis and infect. This term has been restricted by some writers (Dr. A. T. Thomson, Elements of Materia Medica and Therapeutics, 2d edit. Lond. 1835) to those agents that are capable of neutralizing morbific effluvia. It is so employed by the author of the article Disinfection, in this work. The writer has always used it, however, to include antisep- tics. These will be considered here;—the reader being referred to the next article for information in regard to the others. Antiseptics, as the writer has defined them elsewhere (General Therapeutics and Materia Medica, ii. 373, Philad : 1843), are "Substances that are capable of removing any incipient or fully formed septic condition of the living body, or of any part of it." If we grant, that such a septic tendency may exist in the organism, under particular circumstances, we can conceive that antiseptics may be needed in two contingencies : first, to obviate such tendency, and secondly, to correct the offensive character of any of the tissues or secretions that may have become putrid, and thus prevent them from re-acting on the system. Generally, the acceptation of antiseptics includes Vol. I. — 87 3u 690 DISINFECTANTS —DISINFECTION. only agents that are employed when signs of putrescency have already manifested themselves, and when the object is both to destroy the offen- sive character of the tissues or secretions, and to arouse the vital energies, so as to enable the func- tions of nutrition to take fresh activity, and throw off the morbid and morbific degeneration. With this view, the different vegetable tonics, and e>pecially cinchona, with the mineral acids, are commonly exhibited, in order to induce a new action in the function of innervation, — and, through the improved haematosis, to enrich the vital fluid, so that, when it reaches the capillaries, —under the amelioration occasioned by these com- bined changes, — the organs of nutrition may assume fresh activity ; and if a portion of the organism has become dead, and consequently extra- neous, a separation of the dead from the living portions may be more readily accomplished. In this way, probably, most internal antiseptics act; whilst, by passing into the mass of blood, and being exhaled through the different emunctories, they may, at the same time, correct any septic condition or tendency which the different tissues or fluids have acquired. The action of some antiseptics cannot, however, be explained in this manner. This can obviously only be the modus operandi of such as enter the blood-vessels,— wholly or in part. Charcoal probably exerts its efficacy altogether on the first passages, and, through them, on the rest of the economy. It is difficult to conceive, that it can act through the medium of the circulation ; whilst the chlorinated preparations, creasote, &c, produce their effect in the compound mode above described. In like manner, when these and other agents are applied externally to gangrenous or gangrenoid parts, their operation is equally complex. They first of all disinfect, by acting chemically on the parts with which they come in contact, and, as a general rule, stimulate the vital energies of the tissues, until these assume a new action, and throw off' the morbid condition and degeneration. With this view, antiseptics are employed in gangrene, spha- celus, foul ulcers, &c. Some of them would seem to act merely as disinfectants: such is probably the case with charcoal; it merely destroys the putrid emanations, and thus prevents them from acting injuriously on the system. Of the special disinfectants of the living body, the most important are the following : Sulphate of Alumina.—The power, possessed by the aluminous salts, of preserving animal matter has only been appreciated of late years, and chiefly through the labours of M. Gannal; (History of Embalming, &c. translated by Dr. Harlan: Philad. 1840.) M. Gannal prefers the simple sulphate of alumina, made by the direct combination of alumina and sulphuric acid. It has been chiefly to prevent putrefaction in the dead body, that the salts of alumina have been employed. They have, however, at the writer's suggestion, been used in the Philadelphia Hospital as antiseptics and detergents to foul, indolent ulcers, and with decided benefit; (New Remedies, 4th edit. p. 56 : Philad. 1843, and Medical Exa- miner.- Philad. 1843.) Chlorine, in vapour, has been inhaled in gan- [ grene of the lungs, in which it has been found to correct the fetor of the breath and expectoration, and to be, therefore, calculated to obviate not only the local but the constitutional symptoms. (Stokes, Dublin Hospital Reports, vol. 5.) I The aqua chlorini has been given in various ! cases as an antiseptic — as in typhus, scarlatina maligna, cancrum oris, gangrene of the lungs, &c. It has also been used, properly diluted, as a wash to foul ulcers—as a gargle in putrid sore throat, &c. Chlorinated Lime and Chlorinated Soda have been used in like cases. The Muriatic Acid and Empyreumatic Ace- tic or Pyroligneous Acid have also been pre- scribed, both internally and externally, as anti- septics. The latter owes its main properties to the creasote which it contains. This last is rarely given internally : it is sometimes applied to foul, indolent ulcers, to prevent or correct the putrefaction of secreted matters, and to stimulate the parts to a better action. It is also used as a wash in gangrenous stomatitis; and as a collu- tory, when a fetid breath originates in the decom- position of matters in the mouth. Charcoal is occasionally given internally, in septic conditions; but it is most frequently applied topically, as in dentifrices, and foul ulcers. All the different tonics, too, have been prescribed internally, as well as applied externally, in similar conditions. A poultice of powdered cinchona is a common application to foul ulcers, and to gangrenous parts; and a decoction of cinchona, with muriatic acid, is frequently used as a gargle in ulcerated sore throat. Robley Dunglison.] DISINFECTION.—This word, being in some degree new to our language, is here used to ex- press the operations by which we attempt to clear the air and other bodies from the contamination of certain minute particles, some perceivable by the sense of smell, others not to be thus recog- nised, but all producing deleterious effects on the human system. Of those perceptible to the sense of smell the chemical qualities are in general more or less known to us ; of those too, which are not to be thus perceived, we possess some chemical knowledge; but of others we know nothing ex- cepting their deleterious effects on the human sys- tem, and occasionally on that of inferior animals. (See Infection.) However various the sources of contamination, the means which have been resorted to for their correction are reducible to three heads : first, di- luting, with pure air, the atmosphere of the in- ; fected apartment or place; secondly, the admix- | ture of certain gaseous matters with such an at- } mosphere, in order to decompose the infecting par- ticles : or attempting to divest the atmosphere of them by substances which have an absorbing power; thirdly, clearing, by washing, cleansing, and exposure to the air and to disinfect ing agents, the solid matters, such as bed and body clothes, the walls of apartments, &c, of the noxious mat- | ters with which they might infect the atmosphere by slowly giving them out to it. 1. Diluting with pure air (for the means of accomplishing which see Ventilation) is the DISINFECTION. 691 measure which, in all cases admitting of correc- tion, merits the most confidence, and without which all other means are nugatory. It is the sole proceeding resorted to in cases in which the atmosphere of any place is rendered deleterious to life by the admixture of considerable quantities of noxious gases, as of carbonic acid produced by vinous fermentation, the combustion of charcoal, or the decomposition of vegetable matters in a close place ; or of carburetted hydrogen, which is occasionally so copiously evolved in coal-mines ; or where the wholesomeness of the air is impair- ed simply by the destruction of its oxygen, as occurs in the acid fermentation ; or where great numbers of persons are assembled in a place com- paratively small. 2. The decomposition of the infecting particles has been attempted from an early period. Large fires were formerly kindled in the streets of a town where pestilence was prevailing, with this view; but it seems more than questionable whe- ther they can in such a situation produce any beneficial effect whatever, and by enlightened peo- ple they are now entirely abandoned. In a limit- ed quantity of air, however, as in an apartment, or the hold of a vessel, they may be useful, not by acting chemically on miasmata, but as a venti- lating process, by causing a current of air in such situations ; the heated and consequently light air ascending through the chimney or any aperture which may exist, and being replaced by a portion of that from the exterior. The firing of gun- powder in the open air, which has been occasion- ally resorted to, seems destitute of any effect, for we cannot expect any beneficial chemical action from the azote, carbonic acid, sulphate and sul- phuret of potash, which are its products ; neither can there be hoped from it any movement of the atmosphere sufficiently general to be of service ; but in a limited space, by expanding the air, it may certainly cause it to be replaced by a portion of the cooler and more condensed external air. Fumigations with certain aromatic substances, as camphor, benzoin, &c, have enjoyed a degree of reputation probably unmerited, and founded solely on their property of disguising unpleasant odours; but they are now superseded by measures deemed more scientific, which we shall proceed to con- sider. Quick-lime.— This substance, besides its well-known property of absorbing carbonic acid, which is copiously evolved from putrefying masses, appears, too, to absorb other gases which are the result of putrefaction ; at least it has the quality of correcting offensive odours. From its power in this way, and probably from a supposition that it decomposes or absorbs miasmata, it is usual to pour it into privies or drains which emit offensive odours; and when pestilential diseases are pre- vailing to an extent to cause great mortality, it is customary to throw a thick bed of this substance over the corpses in the grave or trench in which they may be deposited. It is applied, too, in the form of whitewash to ihe walls of apartments, in which persons ill of febrile disorders have lain, as a security against any contagious matter which may have adhered to them. Charcoal.—This substance, as is well known to chemists, possesses the property of absorbing gases, and might, on this account, be advantage- ously employed to rid a limited portion of air of hydrogen or other offensive matters with which it is impregnated. It has not, however, been em- ployed in this way ; but the utility of charcoal filters in divesting water of any gases, the products of animal or vegetable decomposition, with which it is contaminated, has long been recognised. Acids. — These have long been supposed to have the power of decomposing contagious mat- ter, or in some mode depriving it of its virulence. The well-known thieves' vinegar owed its popu- larity to this supposed property ; and it is still the custom to dip into vinegar letters and papers which arrive from places where pestilence is pre- vailing. Clothes and goods of all kinds, coming from lazarettos, are exposed to the vapours pro- duced by the slow combustion of sulphur (sulphu- rous acid). But the former being thought too feeble, and the latter having been found exceed- ingly irritating to the lungs, they are rarely em- ployed for general disinfecting purposes; and when acids are used, either the muriatic, the oxy- muriatic (chlorine), or the nitrous is resorted to, though the employment of any of them in an inhabited apartment is not unattended with seri- ous inconvenience to patients and attendants. Muriatic acid was first employed by Guyton Morveau, in 1773, to disinfect the principal church of Dijon, the air of which had become so contam- inated by the emanations from the vaults below, from which, on account of their too crowded state, the bodies had been removed, that it was utterly unfit for divine worship. Vinegar, aromatics, and the deflagration of nitre had been tried without effect; but the vapour arising from the decompo- sition of six pounds of common salt by two of concentrated sulphuric acid deprived the air in one day of all unpleasant odour, and in four days afterwards worship was performed. This distin- guished philosopher, towards the close of the same year, used fumigations of muriatic acid with complete success for disinfecting the prison of Di- jon, whither fever had been imported from other gaols, of so malignant a nature that thirty-one prisoners had perished from it in a very short space of time. The proportions recommended are twelve parts of sulphuric acid of the specific gravity 17- to fif- teen parts of muriate of soda, which should be slightly moistened before the acid is poured upon it. If employed for disinfecting an uninhabited place, flat earthen dishes, containing the mixture, may be placed on a sand-bath, and the whole of the acid may be added at once. If in one occu- pied by patients or others, all heat should be dis- pensed with, and the acid should be added gradu- ally. The latter rules should be considered im- perative in all cases where acids are employed to disinfect inhabited places. Nitrous acid fumigations were first employed j in this country ; and a liberal parliamentary grant 1 was bestowed on Dr. Carmichael Smyth for their I application to disinfecting purposes, which was I regarded as a discovery. A prior claim was sub- sequently set up for Dr. Johnstone, of Worcester. | The fumigations were successfully employed by Dr. Smyth in 1780, for checking the progress of | a fever which prevailed among the Spanish pri- 692 DISINFECTION soners at Winchester, of whom it had destroyed I a seventh part in three months. Several other examples of their utility in disinfecting ships and ! hospitals might readily be quoted. Nitre and sulphuric acid are the substances employed in this I mode of fumigation, and equal parts of both in- gredients are found to be the best proportions. The combination of the salts producing a consid- erable evolution of heat, none should be employed to aid the decomposition. It is calculated that half an ounce of each ingredient will suffice to disinfect an apartment of ten feet in each dimen- sion, comprising of course a thousand cubic feet; and it is advised, in case of our having to apply the method to larger apartments, that we should multiply the cups or saucers which contain the ingredients, rather than introduce a larger quan- tity than that mentioned into one vessel, as the red fumes disengaged might seriously incommode the operator. Oxygenated muriatic acid (chlorine) was first proposed as a disinfecting agent by Fourcroy, in 1791. It was soon after employed by Cruick- shank, of Woolwich, and by Guyton Morveau, who thought it preferable to all other acids ; and it has since united most suffrages in its favour. There is an excellent and concise account, in the eighteenth volume of the Journal of Science and the Arts, of the disinfection of the Milbank Peni- tentiary by Mr. Faraday. To this the reader is referred, as it comprises all that is necessary to be known of the mode of applying fumigations of chlorine to uninhabited places. The following are the material points of the process adopted by Mr. Faraday. He found that one part by weight of common salt, and one part of oxyde of manga- nese, when acted upon by two parts of oil of vitriol, previously mixed with one part by weight of water, produced the best results. The salt was bruised down with a mallet previously to be- ing mixed with the manganese; and the acid and water were mixed in a wooden tub, and allowed to stand for some hours, that the heat produced by their combination might be dissipated before they were poured on the other ingredients. Com- mon red pans, of a flat form, were used for the fumigation. The evolution of chlorine commenced a few minutes after the ingredients were mixed in the pan, and continued for four days, no extrane- ous heat being employed in the operation. The quantity of material used was 7001b. of salt, 7001b. of oxyde of manganese, and 14001b. of sulphuric acid; whilst the space requiring fumigation amounted to nearly 2,000,000 cubic feet, and the surface of the walls, floors, and ceilings was about 1,200,000 square feet. The able arranger of the process is of opinion that from one-half to one- fourth of the chlorine, and consequently of the ingredients employed for its production, would be quite sufficient in a building of the same extent, for any of the usual cases where fumigation is re- quired. The proportions recommended by Guy- ton Morveau differ from those employed by Mr. Faraday. The former philosopher advised that two parts of powdered oxyde of manganese should be mixed with ten parts of muriate of soda, and that the mixture should be acted upon by six parts of sul- phuric acid previously diluted with four of water; and in an uninhabited room, forty feel by twenty, he thought two ounces of oxyde of manganese, ten ounces of muriate of soda, six ounces of sulphuric acid, and four ounces of water, sufficient for per- fect disinfection ; the doors and windows being closed for ten or twelve hours. Chlorine is so powerful an irritant to the bron- chial lining, that its rapid evolution in the pro- cesses described above is quite inapplicable to in- habited apartments or wards, unless the quantities of the ingredients employed are so small in pro- portion to the space to be disinfected that we can- not expect any beneficial result from them. Guy- ton Morveau endeavoured to surmount this diffi- culty by means of his permanent apparatus of dis- infection, which consisted of a glass vessel encased in wood, having its mouth very accurately closed by means of a ground glass stopper, acted on by a vice. A slight turn of the vice allowed the vapours, by their expansive force, to raise the stop- per and mingle with the atmosphere. One-third of the apparatus was occupied by four parts of oxyde of manganese, finely powdered and sifted, ten parts of nitric acid of sp. gr. 1.40, and ten of muriatic acid of sp. gr. 1.134. From this combi- nation the chlorine is disengaged much more slowly than by the action of sulphuric acid on a mixture of muriate of soda and manganese; and by means of the vice the issues of gas are regu- lated at pleasure, whilst the lightness and close- ness of the apparatus enable us to remove it rea- dily from one place to another. The disinfecting bottle, arranged in the manner described, may be opened twice a day, and still retain its disinfecting power for three or four months. However inge- nious the plan of M. Guyton Morveau, this, and perhaps all disinfecting processes—certainly all for occupied wards or apartments—are superseded by the agents more recently introduced by M. Labarraque. This gentleman, an apothecary in Paris, was the first to suggest the employment of chlorine in a liquid form for disinfecting purposes. He recommends two solutions. One, the chloride of lime (a solution of bleaching powder,) is pre- pared by passing chlorine gas over hydrate of lime : this, when dissolved in water, forms Labar- raque's liquid ; or the liquid may be formed directly by passing the gas into water which holds lime in suspension. Two methods are recom- mended for forming chloride of soda, one by M. Labarraque, and the other by M. Payen. The former passes chlorine gas into a solution of car- bonate of soda; the latter decomposes chloride of lime by the carbonate. Both processes are easy, the latter the most so ; and it has been so arranged by M. Payen as to make the resulting compound identical with that prepared by the former method. No carbonic acid is expelled on passing the chlo- rine into the solution of carbonate of soda; the solution has a faint smell of chlorine; when heated, scarcely any chlorine is evolved ; it first acts as an alkali on turmeric paper, and then bleaches it; on the addition of acid, chlorine and carbonic acid are expelled. Chemists do not seem fully agreed as to the precise nature of these compounds, but in a prac- tical work we do not feel called upon to enter into controversies on this point. (See Granville in Journal of Science, &c. vol. xxiii. and R. Phillips in Philosophical Magazine, vol. i. of New Series.) DISINFECTION. 693 It is material to know that they are most powerful disinfecting agents, and that since their introduc- tion by Labarraque they have been applied to every kind of ease in which the operation of such agents is requisite, by innumerable scientific per- sons of various nations, whose testimony is loud in their favour. They appear to act, as the expe- riments ct Gaultier de Cluubry tend to prove, by the evolution of chlorine, from the action of the carbonic acid contained in the atmosphere on the compounds, so that a gradual fumigation by chlo- rine takes place; and where atmospheric impuri- ties abound, the proportion of carbonic acid being generally greater, the fumigation will be more rapid. The following is an abstract of these ex- periments : Well saturated chloride of lime being dissolved in water was submitted to the action of carbonic acid gas; chlorine was quickly disengaged, and by continuing the operation a sufficient length of time, the whole was expelled, the liquor no longer possessing bleaching powers, and carbonate of lime having been precipitated. Air, passed slowly through a saturated solution of caustic potash, to deprive it of carbonic acid, was then made to traverse a solution of the chlo- ride of lime ; no chlorine was liberated, no effect of any kind produced. The chloride of soda is equally decomposed by carbonic acid, only more slowly, in consequence of the solidity of the salt produced. A filtered solution of the chloride of lime was exposed to the air on the 13th of August; on the 10th of October it no longer contained chlorine ; did not affi-ct litmus; and the precipitate from it proved to be carbonate of lime. A stronger solu- tion of the same chloride, exposed to the air on the 16th of August, was found in the same state as the last on the 10th of October. Air was passed through blood, which had been left to putrefy for eight days; being then passed through a solution of the chloride of lime, carbo- nate of lime was deposited, and the air was ren- dered inodorous and completely purified. In a second similar experiment the fetid air was passed through a saturated solution of caustic potash be- fore it arrived at the solution of the chloride; the latter then had no effect upon it, and the air re- tained its insupportable odour. Another experi- ment was made with air left twenty-four hours over putrescent blood ; the portion of it which was passed directly through the chloride was per- fectly purified, but when previously freed from carbonic acid, the chloride had no effect upon it. f Annates de Chimic, xxxiii. 171, and Journal of w«:f nee, vol. xxiii.) These experiments of Gaultier de Claubry seem very conclusive, yet a fact is mentioned by Labar- raque and Parton, in their report to the Council of Health of Paris, on the removal, from the church of St. Eustache, of the bodies which were deposited there during " the three days" of July, 1830, which tends to show that carbonic acid is not uniformly the agent which decomposes the chlorides and calls into action the disinfecting power of the chlorine. These individuals found this process go on very rapidly indeed, though a bed of lime thickly spread over the floor must necessarily have absorbed the carbonic acid; and hence were led to conclade that an exact theory of the phenomenon still remains to be discovered. (See Report, \ Dr. Fowler, for this purpose; and when admin- istered in small doses, either in the form of infusion vf of wine, so as not to nauseate, it has been !.iven successfully in dropsy. Nu diuretic, how- ever, requires so much caution in its administra- tion under the most favourable circumstances; and, therefore, it has been less employed than it deserves to be. Much of the efficacy of foxglove depends on the period of the growth of the plant at which the leaves are collected, and the manner of drying and preserving them. In the months of July and August they are in the best state: they should be then gathered, and dried between colourless bibu- lous paper, in a warm room, and under a moderate pressure. This may appear to be an unnecessary degree of care and trouble, but for the preparation of a medicine of so much activity, and wliich is administered in grain doses, too much attention cannot be bestowed to preserve all its medicinal powers in the only way in which they can be obtained. When the dried pulverized leaves lose their green colour, some chemical change has taken place in them which deprives them of their native properties. In employing foxglove as a diuretic, it should be recollected that its influence on the capillaries is not obtained in states of the habit exceeding the limits of the healthy standard of tone. In states below that point, it stimulates the capillaries, and diminishes the force and fre- quency of the pulse, and operates as a diuretic ; for in dropsical effusions, whether those of ascites or hydrothorax, no benefit can be expected from the employment of foxglove, as long as any ten- sion of the vascular system exists. It is after tapping and a reduction of arterial action, that decisive advantages are obtained from prescribing foxglove in hydropic affections. It is on the same principle that it is most useful in lax, pale, leuco- phlegmatic habits ; and, if the disease be anasarca, ip those cases in which pitting is left on pressure of the affected parts: thence, when this state does not exist, the system must be lowered by blood- letting and purging, before any advantage can be expected from foxglove as a diuretic. It has been found useful to combine it with mercurials, especially the blue pill; and pushing this far enough to affect very slightly the salivary glands: but in cases of either anasarca or ascites, the best adjuncts are bitartrate of potassa, acetate of ammo- nia, or-colchicum ; and in constitutions broken down by protracted courses of mercury, the nitric acid. When foxglove is administered in the form of powder, the dose may be gr. i. repeated for the first two days at intervals of eight hours; after which the intervals should be lengthened accord- ing to the effects produced. An infusion made by macerating one drachm of the dried leaves in f.3 viii. of boiling distilled water, and f.Bji. of cinnamon water, for four hours, speedily produces the diuretic effects of the plant, when given in doses of f.^i. repeated at intervals of five hours. The dose of the tincture should not at first ex- ceed ten minims ; but it may be gradually in- creased until its diuretic influence be perceived. Th/, symptoms of an overdose are nausea, vomit- ing, vertigo, pulsation in the temples, a sensation of heat throughout the body, sweating, sometimes diarrhcea, and occasionally salivation. One re- ' markable symptom sometimes occurs, a suppres- | sion of urine. The best antidotes, under such circumstances, are, ammonia, brandy and water, opium, and the stimulus of a blister applied over | the pubis. One circumstance is particularly ne- j cessary to be noticed in prescribing digitalis—its I power of accumulating in the system, like mer- cury, and suddenly exerting its specific effects when not expected. No medicine, therefore, re- quires to be more closely watched, whether it be given in moderate doses, long-continued, with the view of obtaining diuresis; or administered in I gradually augmented doses, to lull delirium and I procure sleep in mania. Whenever nausea is felt, j it must be noticed and suppressed ; for vomiting arrests the diuretic influence of the remedy. Little requires to be said of Jactucarium as a diuretic. It has been found useful in hydrotho- rax, and some other cases of dropsical effusions, by the German physicians; but in this country | its place is much better supplied by foxglove. All bitter tonics possess, more or less, diuretic J effects ; but the seneka root is perhaps better i adapted for this purpose than any other : its in- fluence is particularly felt in those cases in which , the serous accumulations are the effect of general debility; as for example, those cases of asthenic ascites which sometimes follow acute diseases. In such cases, also, much benefit is obtained from the ferrum tartarizatum, which, besides operat- ing as a tonic, has a direct diuretic influence, and j has been found peculiarly serviceable in cases of anasarca connected with affections of the heart; but in these cases its employment must be pre- \ ceded by purgatives arid mercurials. With respect to the employment of mercurials, much benefit ! is derived from their aid in promoting the opera- I tion of other diuretics. Thus the diuretic effects of squill are rendered more certain when combin- I ed with calomel; and those of digitalis when ; united with the blue pill. In both instances the stimulant influence of the mercurials on the capil- lary system aids that of the active principle of the other diuretics, and more benefit seems to re- | suit from such combinations than when either is | administered alone. From the view which we have given of the substances most commonly employed as diuretics, the practical employment of them as remedial agents may be very briefly stated. In febrile af- fections much must be done before prescribing diuretics ; but in long-protracted fevers, whether j intermittents or continued fevers, if cedematous swellings occur, their use is indicated and must J not be delayed. If they be prescribed during con- tinued fever, it should be recollected that one of the most distressing occurrences in that disease is retention of urine; and, therefore, in prescribing diuretics, it is highly requisite to examine daily the state of the bladder. Most fevers in their ter- mination display critical changes either in the quality or the quantity of the urinary discharge : under such circumstances, it becomes a question —how far are diuretics likely to favour such a crisis ? At the commencement of fevers the urine is generally pale ; it becomes afterwards high-co- loured ; and at the termination of a paroxysm, if DIURETICS —DROPSY. 701 the fever be intermittent or remittent, or, when it begins to decline, if it be of the continued type, a sediment either lateritious or of a pale pink co- lour is deposited, and has been regarded as criti- cal. JJut this sediment is to be regarded rather as the result of a certain catenation of actions, than as the excretion of any thing injurious to the habit; and, were diuretics able to promote it, they would be of no avail. Upon the whole, therefore, even as simple evacuants, diuretics are of little value, either in idiopathic fevers, or in acute diseases in which fever is a svmptom. They have been advantageously administered in many chronic affections, especially those accompanied with eruptions on the skin ; but the chronic affec- tions in which their influence is truly beneficial are dropsies. This class of diseases depend on such an atony of the capillary system, that in- stead of the capillaries carrying forward the fluids they contain, they pour them out into the serous cavities, and thence the balance between the exha- lation and absorption which exists in health being broken, the effused matter is accumulated to a degree which overpowers the absorbents. Diure- tics are prescribed to cure dropsies in nearly every form; and do so by stimulating the capillary sys- tem, so that no fresh effusion taking place, the absorbents are enabled to take up the already effused fluid, and to throw it upon the kidneys, its natural einunctory. When success attends the administration of diuretics in dropsy, one advan- tage resulting from their employment over drastic purgatives and some other remedies is, the little debility which they occasion. If diuretics, how- ever, be given alone, they are uncertain in their effects, and seldom in that case deserve more than the title of palliatives; but, as adjuncts to other means, they aid materially the evacuation of the effused fluid, and have thus frequently effected the removal of general dropsy. Their success, however, is very precarious; and so many cir- cumstances interfere with their operation, that it is difficult to form a prognosis of their expected effects. Sometimes they operate freely, increas- ing greatly the discharge of urine, and yet the dropsical swellings continue. In this case some organic mischief must be looked for; and unless this can be removed, no great advantage can be expected from the evacuation of the effused fluid. The kinds of dropsies in which direct diuretics have proved most beneficial are anasarca and ascites ; whilst those which operate by diminish- ing arterial action, and augmenting that of the capillaries, are the best adapted for hydrothorax. But even in any case the influence of diuretics hinges upon so many accidents, that all of them arc precarious in their effects. In encysted drop- sies they are utterly useless, unless preceded by reducing the sac to the state of an extraneous body. Diuretics have been much prescribed in calcu- lous diseases; and most of the substances called lithontriptics are diuretics. We have ample proofs that none of them act chemically in dissolving calculi; nor, indeed, can they be said to be capable of effecting any change on the kidneys sufficient to prevent the formation of calculous matter. It is probable that the benefit accruing from their employment is wholly due to their influence on 3i* the digestive organs; and by their aiding in the formation of a better gastric juice, the digestive process being rendered more complete, all the se- cretions, and consequently all the excretions, must necessarily become more healthy, and cease to deposit the uric and other acids in the pelvis of the kidney. In conclusion, we would say that the efficacy of this order of remedies depends more on the tact of the prescriber, and his intimate acquaintance with the changes, both structural and functional, which disease produces on the system, than any other. The operation of no other order of medi- cines is so much modified by circumstances; and no other medicines require so much attention as these for insuring their beneficial effects. The following rules ought always to be strictly ob- served during the administration of diuretics. 1. The surface of the body must be kept cool. 2. The use of diluents is essential, and ought always to be urged, more especially when the saline diuretics are employed. 3. The patient should, if possible, be out of bed during their operation. 4. The diuretic should be administered in the day-time. 5. After the accumulated fluid has been re- moved from the serous cavities, and the use of the diuretics suspended or discontinued, tonics should be prescribed. G. Little advantage can be anticipated from the employment of diuretics in those dropsies which originate from organic affections of the liver or the chylopoietic viscera, and still less in encysted dropsy. It is only in those cases connected with debility and deranged action of the capillary sys- tem, that diuretics can be regarded as certain remedial agents. A T Th0MS0N- DROPSY. (From the Greek, Mpu^ — Lalin; hydrops: —Th. Uwp, water, and <5t/<, the look or aspect.) Dropsy is a common term signifying effusion into the cellular tissue, or into any of the natural cavities of the body. With the addition of the epithet encysted, it has likewise been em- ployed to designate a very different series of affections, viz., those collections of serous fluids which are contained in factitious sacs, and of which the ovary is more peculiarly the subject. These, as having neither the same origin, nor ad- mitting the same treatment, will be spoken of in a separate article. Even real dropsies differ so much from each other, in consequence of the organs in whose neighbourhood or in whose substance they form, that they cannot all be comprehended in one arti- cle. Thus hydrocephalus, though agreeing in having as one of its terminations an effusion of serum into the ventricles of the brain, can by no means be regarded in the same light with effusion into the larger cavities of the body. Its progress is more rapid, its origin more decidedly inflamma- tory, and, when it assumes a chronic form, it never gives rise to anasarca, which almost con- stantly attends hydrolhorax or ascites. Hence, therefore, under the common head of dropsy, we can only consider this and other local dropsies, so far as the same theoretical explanations of their phenomena agree with each other ; and our chief 702 DROPSY. attention must be paid to the form, origin, and treatment of what is commonly denominated ge- neral dropsy. For the peculiar symptoms by which hydrocephalus, hydrothorax, and hydrops pericardii are indicated, we refer to the articles under which these affections are treated. The ancients appear to have had very crude notions of the cause of dropsy, and any approach to a rational theory of the disease is of very mo- dern origin. Hippocrates explained its occurrence by the corruption and softening of the flesh, and its conversion into water. Celsus states that the common cause of dropsies is too great an abun- dance of humours. Galen, attempting greater refinement, referred it to refrigeration of the liver, which he assumed might happen either from an affection of that organ itself, or from sympathy with other organs; and with little modification this theory of Galen was received in the schools till after the discovery of the lymphatics by Asel- lius. Forestus, who wrote in the latter part of the sixteenth century, adopts the opinion of Celsus, and explains it by the theory of Galen. He as- sumes that in consequence of the refrigeration of the liver, the veins also become refrigerated : hence a more serous state of the blood and greater abundance of water; and hence, according as the affection is local or general, anasarca or ascites is produced. Fernelius, apparently seeing the insufficiency of this theory, referred anasarca to refrigeration of the liver, and ascites to a rupture of the vessels which contained the humours. By these, how- ever, it is scarcely possible that he could intend the lymphatic vessels, as he wrote before the dis- coveries of Asellius had been published, and long before these vessels were supposed to be so general as it is now known that they are. Sennertus, following Fernelius, made a some- what nearer approach to a rational theory ; for while he adopted the old doctrine with regard to anasarca, he attributed the occurrence of ascites to obstruction of the liver and spleen, by which means the vessels were distended with fluid, their extreme mouths dilated, and an escape of serum permitted into the cavity of the abdomen. The discoveries of Asellius gave rise to a different theory, and dropsy was referred to a rupture of the lymphatics. Judging from the language of Lower, it might be supposed that this doctrine had obtained considerable support, when the well- known experiments of this physiologist laid the foundation for a more rational explanation of the phenomena of effusion than any which had yet been given. By tying first the inferior cava, and afterwards the jugular veins, he did much more than any of his predecessors—he proved that ef- fusion might be caused by obstruction in the veins. Neither Sydenham, nor Mead, nor Willis appear to have concerned themselves much with the the- ory of dropsical effusions, but were content with simply inculcating particular modes of practice. Soon after Mead, or even while he was yet living, Haller was laying the foundation for more rational explanations of the phenomena of dropsy. He adopted the then general theory of absorption by the veins, and lays down distinctly that dropsy may ensue, not only when the veins are obstruct- j ed, but when the course of the blood through the veins is retarded by debility, whatever may be its source.* Haller did not acknowledge the absorbing office of the lymphatics, but even when, in consequence of Dr. Hunter's doctrines, absorption was entirely referred to those vessels, it made no difference in the theory of dropsical effusions. It was only necessary to change " veins" into " lymphatics," and it was supposed that a sufficient explanation had been given. Such is a short outline of the attempts which have been made to explain the phenomena of dropsy ; and at the beginning of the present cen- tury the general opinion seems to have been that the disease depended upon defective absorption, and that it was essentially a disease of debility. The investigations of various writers into the | causes and treatment of hydrocephalus, which ! served clearly to prove that this disorder had very frequently an inflammatory origin, naturally tended ' to re-open the general question ; and Blackall, Abercrombie, and many others were led to teach that both anasarca and ascites are often attended with and dependent upon inflammation. Former writers had indeed given examples of dropsies ! successfully treated by bloodletting; but these for ( the most part were single cases; and no attempt [ to lay down any general plan had been made till the time of the writers just referred to. Multi- plied experience has now determined the question of treatment; and that in many cases an anti- phlogistic plan is requisite, is no longer a matter of doubt. But whether dropsy depends upon in- creased exhalation or diminished absorption, is yet undecided ; nor do we feel that the facts are sufficiently numerous to determine the dispute. We shall shortly give the principal arguments for either theory. That dropsy proceeds from deficient absorption | is argued, because, whether we consider the veins j or lymphatics the instruments of this function, pressure upon their trunks is followed by an effu- sion of serum into the parts farthest removed from the heart. This, indeed, till some late experi- ments by Magendie, was the only real fact which could be adduced in favour of diminished absorp- tion. This physiologist, by inducing an artificial plethora, and then showing that the function in I question was less actively exercised than in those | cases where no such plethora existed, has certainly given additional probability to the theory, and, under any circumstances, has proved what before was purely hypothetical—that absorption is capa- ' ble of being diminished. On the other hand, that increased exhalation is the cause, is argued from the circumstance that absorption actually proceeds in dropsy, that the fat is taken away, and that emaciation advances pari passu with the effusion; | that this function is always the last to yield, and I that it appears to become more energetic in pro- portion to the general debility of the system ; that the exhalents are capable of pouring out very dif- * Sed etiain absque ejusmorti cansis hydrops nasci vi- defir, quoties dehilitas sliqnn, utideemique nata, iter Vfiiosiim inrriat. Facile eniin intellisittir, in universiiiii ! riiiitins sanguinis per arttrrins im.tum siiperissu, quein cor proxiniiim tPP:i-t, prinrem vero muMm vennrn'in qui- i esrere. Et'/o si arleria iwlnilare peruant. vena; resorbere | t-Cssuul, collectus vapor in hydropuin abibit. DROPSY. ?03 ferent quantities of fluid, as is seen in the secre- tion of tears, the sudden increase of perspiration, &c.; and, lastly, that the fluids effused are differ- ent from the natural secretions of the parte, con- taining a much greater quantity of serum ; and that this difference would not exist if dropsy were the simple result of diminished absorption. A far more important question, however, to the practical physician, is the condition of the system under which effusion takes place—whether'it be a sthenic or asthenic state. Whether we adopt increased exhalation or diminished absorption as the source of effusion, this question will admit of the same decision. Effusion may clearly take place in a state of debility and in a state of undue activity of the system, or of plethora. With re- gard to absorption, the experiments of Magendie have clearly proved that plethora is unfavourable to this function ; and that it is favourable to in- creased exhalation, the profuse perspirations of persons having a full habit clearly evince. If such individuals are bled, the tendency to per- spiration either yields entirely or is greatly dimin- ished. We have therefore to investigate carefully, in every case of dropsical effusion, the general state of the system by which it is accompanied, for what may be proper for one state will most un- doubtedly be injurious to the other. The only points, then, that we can assert as proved in the theory of dropsy, are—first, that the balance between exhalation and absorption is broken, in consequence of which more fluid is poured out than is taken away ; and, secondly, that this may take place from over-activity or from debility of the general system. Something may attach also to the condition of the blood, but upon this point we have very little satisfactory information. That hemorrhages in- crease the serous portion of the blood, and that profuse hemorrhage gives rise to dropsy, is cer- tain ; and that in dropsies, more especially those accompanied with extreme debility, the blood often exhibits a remarkable difference in the proportions of serum and fibrine, in its coagulability and in its colour, is likewise certain; but we have yet no data by which to connect these phenomena with dropsy as cause and effect. Almost the only information, till the late ad- vancement of chemistry, which had been obtained respecting the nature of the fluids effused in drop- sy, regarded the colour and taste, although in a few instances the consistency and coagulability had been noticed. They have been described as a yellowish serum, as being of the colour of urine, Orange-coloured, saponaceous, purulent, bloody; and, in one instance, Morgagni observed the fluid to coagulate without heat. For a more particular account of these flunls we are indebted to Marcet. He examined them in hydrocephalus, ascites, hy- drothorax, and in most other dropsies; and he has given a detailed account of the result in the second volume of the Medico-Chirurgical Trans- actions. According to this statement, the prevail- ing animal substance is albumen, which is con- tained in very different proportions. There is also a peculiar animal substance which Dr. Mar- cet names muco-extractive matter, from its being uacoagulable, but soluble in water and other men- strua. Gelatine was not discovered in afny of these fluids. In the fluids of ascites, hydrothorax, hydrops pericardii, hydrocele, and that which is sometimes effused"in the thyroid gland, the albumen is so considerable as to render them coagulable; while in that of spina bifida and hydrocephalus, it is so small in quantity as scarcely to be rendered visi- ble by heat or acids. The specific gravity is ex- ceedingly various both in different dropsies, and in the same dropsy at different periods. These differences, however, are found to affect principally, if not exclusively, the animal matter only of dropsical fluids; the saline matters being by no means subject to similar variations. The particular saline ingredients of all these fluids are muriates of soda and potash, sulphate of potash, soda and phosphate of lime, iron, and magnesia. A hundred grains appear to consist of about seventy-two grains of muriate of soda, mixed with a little muriate of potash; between eighteen and twenty grains of soda, brought to the state of subcarbonate; and a mixture of eight or ten grains of sulphate of potash, phosphate of lime, phosphate of iron, and phosphate of mag- nesia. The caustic, alkali contained in these fluids, Dr. Marcet proceeds to say, appears to be combined with the animal matter in a manner not well un- derstood, and the proportion of the uncombined alkali to the other salts is greater as the specific gravity is more considerable. To this account of the animal fluids Dr. Marcet has subjoined the following table, to show the proportions of saline and animal matter in various dropsical or serous fluids, and in the serum of the blood. Fluid of spina bifida . 1007 Hydrocephalus........ 1006 7 Ascites............... 1015 Ovarian dropsy.......! 1020.2 Hydrothorax .........' 1012.1 Hydrops pericardii-... j 1014.3 Hydrocele............I 1020.3 Blister................j 1024.1 Serum of blood........! 102SI.5 Sp. Gr. Grains- Grains. 14.4 9.2 33.5 2.2 1.12 25.1 206 33 80 18.8 25 5 71.5 100 90.8 ■ Bag at Grains. 9.2 8.08 8.4 8.0 7.8 7.5 8.5 8.1 9.2 The specific gravity here stated is an average. I. Dropsies may be acute or chronic, idiopathic or symptomatic, primary or secondary, general or local, inflammatory, sthenic, asthenic, &c. These varieties occur in every cavity in which dropsy itself takes place, but the different forms are more common in one cavity than in another. Thus, the brain is most frequently the subject of acute dropsy ; the pleurae and pericardium hold the next place in this liability to acute effusions, and the peritoneum the last. The cellular texture is per- haps on an equality in this respect with the pleura I and pericardium, but it is seldom affected without some organ suffering at the same time, in whose action it participates. Dropsy of the stiienic cha- racter is for the most part an acute, but not always an inflammatory disease. It chiefly assumes the form of anasarca. (See Anasarca.) Sometimes it appears to be purely idiopathic, and unattended by disease or affection of any particular organ. 704 DROPSY. In this case the anasarca takes place very suddenly, the whole cellular tissue sometimes becoming in a few hours enormously distended with fluid ; and there is considerable heat of skin, with a full and hard pulse, furred tongue, and much thirst. Not unfrequently the patient complains of tenderness over almost the whole surface of the body, espe- cially if strong pressure be made, so that we might be induced to believe that the cellular tissue under these circumstances is in a state of inflammation, i The bowels are generally costive; the urine coag- ulates on boiling, the precipitate thus formed be- | ing very various in quantity.—sometimes scarcely , rendering the urine at all muddy, at others form- ing almost a solid mass. This state of the urine, it has been inferred, is conclusive of disease in the kidney ;* but we shall in the course of this arti- cle afford reason for questioning this inference : it certainly indicates a disordered function of this organ, and not unfrequently accompanies structu- ral disease of it. Much more frequently acute dropsy is accom- panied by inflammation of the lungs or pleura, and sometimes of both. The pulmonary symp- toms, however, are not always very prominent, and they sometimes nearly disappear when the effusion has taken place. In such cases, inquiry into the history of the patients generally shows that they had suffered for several days, or occa- sionally several weeks, from cough and dyspnoea, and that about the period at which these symptoms diminished in severity, the face was perceived to swell in the morning and the legs at night, and the abdomen, without being very perceptibly enlarged, would not allow the clothes to be but- toned or laced so tight as usual. From this time the swellings increase rapidly ; the whole cellular tissue becomes affected, and the countenance is very leucophlegmatic in appearance. At other times the pulmonary symptoms and effusion pro- ceed pari passu, or the former precedes the dropsy only by a few hours, but is not relieved by the occurrence of effusion. The progress now described is generally exhi- bited in the acute anasarca, from whatever source j it may have derived its origin; but not very seldom I effusion takes place to a considerable extent into I the abdomen at the same time, and the ascites quickly becomes equally marked, if not the more prominent symptom. Ascites is much less frequently an acute disease than anasarca, and in most cases is the result of previous inflammation. In the article Ascites we have described several instances of this kind. The exciting causes of acute dropsy are,—the repression of eruptions, the sudden suppression of perspiration, suspension of the catamenia, or of any other customary evacuation, inflammation of the lungs and pleura, exposure to cold, &c. It also succeeds scarlet fever, when this disease has run its regular course. ; sometimes it has suc- ceeded parturition, coming on suddenly and without any pain. In this last case, ascites alone is often observed; but at other times it is accom- panied by excessive anasarca. The ascites suc- ceeding parturition is also at times very manifestly dependent upon peritoneal inflammation, and is * Dr. Bright, however, to whom this notion owes its origin, by no means carries this doctrine so far. attended with fever, quick, small, wiry pulse, and excessive tenderness of the abdomen, &c. These symptoms precede the effusion, and the tenderness diminishes, but does not entirely disappear upon its occurrence. In some of these cases, when the abdomen has been emptied, we have discovered an enlarged ovarium, and we are inclined to believe that it is to the irritation produced by dis- ease of this organ, with the additional stimulus of the puerperal state, that the effusion is owing. The termination of such cases is various : in some, after the disappearance of the dropsy, the tumour remains quiescent, and is not attended by any inconvenience; in others the ascites, indeed, is removed, but the ovary continues to enlarge, and we have at length encysted substituted for peritoneal dropsy. Dropsy may be acute as to the rapidity of its formation, and yet be the very reverse of an inflammatory disease. This variety is, however, much more rare than the preceding species, but, like it, assumes the form of anasarca or of ascites alone, or of both together. It comes on in general very rapidly, and is unattended by fever or any symptom of increased arterial action. In the arti- cle Anasarca an instance has been mentioned, taken from Dr. Bateman's reports of Diseases in London, where it came on after excessive fright, and was removed by the administration of cin- chona. In the form of ascites we have several times seen it follow parturition ; the patient being, within a few days of delivery, as large or even larger than at the period of labour. In these instances the only striking symptom is debility; there is neither thirst, nor heat of skin, nor quickened pulse; and the patient appears to suffer no other inconvenience from the effusion than what proceeds from the increase of her bulk. The progress of such cases towards recovery is very slow, and is always impeded by violent depleting remedies. The most successful plan of treating this affection is generally by slight tonics, frictions over the bowels, and bandaging. It ought, how- ever, to be remembered that such patients are liable to become the subject of sub-acute inflam- mation ; and unless great watchfulness be prac- tised, the disease from this cause may become incurable. Of the same asthenic character are those forms of effusion which are the consequence of any excessive discharge, and more especially hemor- rhage. We have mentioned one instance in the article Anasarca in which the hemorrhage was the consequence of diseased uterus; and the ana- sarca (the form such dropsies generally assume) appeared and disappeared, as the hemorrhage pre- vailed or was suspended. Any other debilitating discharge will unquestionably lead to similar results. II. We shall now proceed to notice those spe- cies of effusion which are always the result of some organic disease, and which may therefore be termed symptomatic or secondary dropsies. They are usually chronic in their course, are seldom attended with acute inflammation, but very frequently accompanied with nub-acute in- flammation. Dropsy from Disease of the Heart*__ | [Cardiac Dropsy.] — This species of effusion is DROPSY. 705 usually preceded by the common symptoms of disease of this organ, and such disease may pre- cede, and often does precede, the occurrence of dropsy for months, and even for years. The first symptom of dropsy arising from dis- ease of the heart is usually observed in the face, the eyelids being puffed in the morning, and an unusual difficulty of opening them being expe- rienced. This single symptom frequently endures for a very considerable time before any farther progress is observed. Next, the feet swell at night, and the upper extremities become very quickly the site of effusion, and the left arm earlier and more frequently than the right. The anasarcous swelling, which is peculiarly pellucid, usually long precedes the occurrence of ascites; effusion taking place in the peritoneal cavity late in the disease and very slowly. Fre- quently, indeed, patients are examined, in whom anasarca has been the consequence of cardiac disease, without a single ounce of fluid being found in the abdomen ; and sometimes, although more rarely, not even in the cavities of the pleurae. The pulse is not always characteristic of disease of the heart; and of course the same difficulty must naturally occur in detecting such disease, whether accompanied or not accompanied by dropsy. When, however, effusion begins after long disease, and without pulmonary symptoms, in the face and upper extremities, we may always suspect the heart to be the source of the effusion. In many patients, and particularly in women, this first symptom appears to be followed by partial cffusi'in into the chest, and for some weeks befo* any farther progress is made, the patient is unable to lie down. At first this difficulty of preserving a reclining posture is very slight, and only an ad- ditional pillow is required, the patient at this time being scarcely sensible that the inability of lying down is the consequence of disease. Gradually, however, the effusion increases, progressively in- volving every part of the system — the cellular texture and the cavities of the brain, pleurae, and peritoneum. The urine in some of these cases at a very early period affords a very slight deposit of albumen upon boiling, and this albuminous secretion be- comes more and more abundant in the progress of the disease. Its quantity varies considerably. In a patient who died in the Birmingham Hospi- tal during the present year at a very early stage of the effusion, two months before his death the urine was barely rendered turbid, but the evening he died it was rendered nearly solid, by boiling. On dissection, the heart was found enormously enlarged, and the aorta very much diseased. The kidneys were perfectly sound. The urine, how- ever, does not coagulate in every case of dropsy arising from disease of the heart, nor is it very easy to say what is the precise state of the system in which this phenomenon does occur. None of the species of dropsy is more frequently relieved, or we may say for a time even cured, than this ; but it very frequently recurs, and at length, favoured by the exhaustion from long dis- ease, and sometimes perhaps even by the remedies that have been necessarily employed, a very co- pious effusion takes place into the chest, and death often at last occurs very suddenly. Some- Vol. I. — 89 times, and this is no unusual occurrence, the anasarca permanently disappears for some time before d»iith, or remains but in a very slight de- gree. The oppression of the chest, however, is not diminished, and occasionally a greater deter- mination of blood takes place to the lunirs, or these organs become congested, especially if much obstruction occurs in the valvular structure of the left side of the heart. At this period haemoptysis, acute pneumonia, and pleurisy, are very liable to ensue, and require the most decided antiphlogistic treatment. Even this treatment does no more than afford temporary relief, and inflammation occurs again and again, till the means of the phy- sician are exhausted. To stimulate increases the inflammation, and farther depletion is rendered impossible by the extreme debility of the patient. The course now described is not peculiar to any one affection of the heart; the symptoms are, more or less, the same under every malady of that organ. Some difference nevertheless exists according as the heart is the subject of what Corvisart calls active or passive aneurism; congestion and in- flammation being more common in the former affection than in the latter. Often, indeed, when passive aneurism exists, advantage is derived from the lighter tonics united with diuretics, but active depletion is neither called for nor admissible : it reduces the patient without benefiting him as re- gards the disease. Dropsy from Disease of tlie Tilings*__ Under the head of Anasarca we have given se- veral instances of this affection, when arising from or connected with inflammation of the lungs. For the phenomena attending it under such circum- stances, we refer therefore to that article. It is not, however, only after inflammation of the paren- chymatous structure of these organs that effusion occurs; it arises also after chronic bronchitis; after chronic pleurisy ; and frequently, perhaps generally, in a greater or less degree, in the latter stages of tubercular phthisis. The phenomena of dropsy, when arising from chronic bronchitis, do not materially differ, except- ing as to the rapidity of its progress, from a simi- lar affection after inflammation of the lungs. The face and upper extremities are in both cases the first to become oedematous. Sometimes this oedema is so slight, that it produces only slight stiffness at first waking in the morning, and is scarcely—oc- casionally not at all—recognised by the patient as the consequence of any swelling of the eyelids. At a shorter or later period after this, the ankles swell, and the affection in this stage may remain ! nearly stationary for months and even for years. As, however, chronic bronchitis is liable to pass at particular periods into a sub-acute, sometimes even into an acute form, there is usually at the | same time an increase in the effusion, which will thus be found to increase and subside with every aggravation or alleviation of the original malady. Wc have in this manner known an individual pass seven or eight years without any material alteration ; in the summer enjoying g. tolerable state of health, in the winter threatened with a fatal termination from fresh attacks. It ought also to be observed, that each attack leaves the individual in a less favourable state than before. At length the dropsical effusion begins to increass 706 DROPSY. more rapidly; the whole cellular texture becomes anasarcous ; fluid is poured out into the cavities of the peritoneum, the chest, and the brain, and death ensues from the affection of one of these latter cavities. Sometimes the pleura, the peri- cardium, and the cellular texture of the lungs become so dropsical, that the patient is unable to lie down, and at last appears to die from suffoca- tion ; and not unfrequently death takes place very suddenly under such circumstances. Another termination is in effusion into the ventricles of the brain, and the patient dies with the common symptoms of apoplexy, or falls into a doze, and imperceptibly passes from a state of sleep to actual death. To this general description of the course which dropsy from chronic bronchitis pursues, is to be added, the supervention of fresh symptoms as ad- ditional organs become involved. Thus palpita- tion of the heart supervenes with the effusion of fluid into the pericardium ; the dyspncea increases with the increase of effusion into the pleura? or the cellular tissue of the lungs ; the digestive or- gans become more disturbed as their functions are interfered with by the pressure of fluid within the cavity of the peritoneum; and if the brain is in- volved in the general disposition to dropsy, stupor, paralysis, or apoplexy, may and not unfrequently does ensue. Dropsy likewise takes place in the latter stages of chronic pleurisy and tubercular phthisis, but it is not often a very prominent affection, and is chiefly confined to the lower extremities. Some- times, however, the body becomes universally anasarcous, especially in phthisis,—and very little can be effected for the effusion under such hope- less circumstances. Dropsy from Disease of the Liver, [Hepa- tic Dropsy.]—This species of dropsy has been re- cognized from the very earliest periods of medicine of which any record remains, and to this most of the older histories of dropsy refer. The form which it assumes is chiefly that of ascites; and some peculiar symptoms attend its progress, which deserve consideration in its treatment. Dropsy takes place in the latter stages of most hepatic diseases; nor are we acquainted with any mode of detecting the precise nature of such diseases during life,—whether there is nutmeg liver, or simple enlargement of it, or tubercular disease,— excepting in the last instance, when the bulk of the organ has so far increased that a tolerably cor- rect opinion may be formed by external examina- tion. Disease of the liver usually exists for a long time before effusion takes place, and its earliest symptoms are little more than those of simple functional dyspepsia. There is flatulence, unea- siness at the stomach after eating, and often some pain and tenderness in the right hypochondrium ; and occasionally at a very early period the lower edge of this organ may be perceived harder, larger, and lower in the abdomen than is usual. There is a short dry cough occurring at times through- out the day, but more particularly on first rising in the morning, and the sputa are blackish and occasionally dotted with blood. The pain passes sometimes backwards under the blade-bone ; at other times the muscles covering this bone, with the deltoid, become the seat of pain greatly re- sembling rheumatism, and not unfrequently mis- taken for it The urine is very red and deposits lithic acid, and the evacuations are usually, but not invariably, clay-coloured. In many instances sickness also is present, and a greater or less de- gree of jaundice. When this last symptom is united with those above enumerated, no doubt can remain that the liver is the seat of some important disease. When the symptoms now mentioned have con- tinued for some time, the ankles are perceived to swell at night a little, and the abdomen becomes somewhat fuller. The urine at the same time di- minishes in quantity, the skin becomes dry and harsh, and the patient suffers from distressing thirst. The progress of the effusion from this pe- riod is very various; in some cases ascites is quickly formed, and the lower extremities become anasarcous throughout; in others the ascites is complete, while there is scarcely any oedema pre- sent; and in a third series of cases, the progress of both is very slow : in these last the ankles re- main long slightly oedematous without any in- crease of effusion, and sometimes for two or three weeks together it entirely disappears, so that the patient fancies that the dropsical tendency is gone ; again however it returns, and the dropsy becomes permanent. The duration of the disease is like- wise various; for while in most cases several months elapse from the commencement of effu- sion till the death of the patient, in others the effusion takes place only a few days, or two or (fcree weeks before death ; and we have some- times seen the abdomen become excessively dis- tended three or four days only preceding dissolu- tion. As in dropsy from disease of the lungs, fresh symptoms are added as additional cavities become the seat of effusion ; but neither the chest nor the ventricles of the brain so readily pour out fluid as when the dropsy commences with an affection of the heart or of the lungs. The dyspncea which usually comes on in the latter stages of hepatic ascites, is chiefly to be referred to the protrusion of the diaphragm into the cavity of the chest, and it is seldom that any cerebral disturbance exists in these cases. Generally, indeed, hepatic pa- tients preserve their intellectual powers to the last in a very extraordinary manner. We have some- times however seen delirium come on in a few hours, or a day or two before death ; but this is so usual in the closing scene of all chronic diseases, that it cannot be regarded as an essential part of the affection we are now describing. Under these circumstances the patient gradually wastes away ; and death seems the natural result of a de- bility that had been continually increasing till the moment of dissolution. Dropsy from Disease of the Spleen and Pancreas*—There are no general symptoms by which we can readily recognise these organs as the sources of effusion. With regard to the spleen, its enlargement usually long precedes the occurrence of dropsy; and the diagnosis, conse- quently, whin the patient is seen early, can sel- dom be difficult. Dropsy from this cause often disappears; and we have known in one instance the effusion and the tumour vanish together, after DROPSY. 707 the latter had existed for many months. The pancreas has not been much observed in dropsy, and we are not acquainted with any case of effu- sion that could be attributed to an affection of this organ. Dropsy from Disease of the Kidneys [Renal Dropsy]. — Many affections of these or- gans are capable of inducing effusion, and this is a common consequence when from any cause j they are extensively diseased. The kidney is oc- casionally converted into a scrofulous mass; and we have met with cases, and several others are recorded, in which under such circumstances it formed a prominent tumour in the abdomen. A much less degree of disease is, however, sufficient to produce effusion. The form of dropsy under these circumstances is anasarca, and ascites does not usually take place till later in the disease. The oedema commences in the lower extremities, and in some instances which have come under our notice, the limb corresponding with the diseased kidney, where only one was affected, has swelled most; so that we are induced to believe that oede- ma in such cases is sometimes the consequence sf pressure upon the ascending cava, or at least is aggravated by this pressure. Dr. Bright has within these few years brought to the consideration of the medical world a pecu- liar ehangc in the structure of the kidney, which he regards as the cause of dropsy, and the ten- dency to which change, or its actual occurrence, is indicated by the coagulability of the urine— [Albuminuria. (See Kidney, Diseases of the)]. In these views he is joined by Drs. Chris- tison and Gregory, the latter of whom has how- ever shown that the peculiar alterations alluded to by Dr. Bright, and the presence of coagulable urine, often occur without dropsy. The peculiar nature of this change we shall intimate when we describe the morbid anatomy of dropsy. Three forms of dropsy connected with disease of the kidney may be particularly traced in the cases recorded by the above-mentioned physicians: — the first commencing evidently with the respi- ratory or circulating organs, and united, either from the beginning or as the effusion proceeds, with disease of the kidney ; the second, commenc- ing with disease of the kidney, and secondarily affecting respiration and circulation ; and a third in which the kidney is the only organ affected throughout The first species differs little from that which we have already spoken of under the head of dropsy from disease of the lungs, except- ing in the supervention of symptoms indicative of renal disease. These symptoms are sickness, vomiting, purging, pain in the loins, often united with coagulable urine ; but this last may exist in a very great degree, and for a very long time, without any appreciable alteration in the structure of the kidney. The former symptoms exist in very various degrees, either alone or united, and are sometimes altogether absent. The second form begins with anasarca only, which quickly becomes universal, and in a longer or shorter time, commonly within a few days, symptoms of inflammation of the lungs or pleurae, or of both, supervene; and though this may be organs, and sometimes also extending to the peri- cardium, and giving rise to adhesions between ite surfaces. The dropsy also is, at the commence- ment of the disease, often easily removable, but still it returns, till at length a few weeks or days before death it disappears altogether. In these cases, it is frequently only the anasarca and ascites that disappear, and the cavities of the chest are found after death to be full of effused fluid. In this as in anasarca from other causes, effusion may take place in the brain; and knowing the sympathy between the kidney and this organ, it is by no means surprising that this is no unusual occurrence. The third is a much rarer occurrence than the two former. Dr. Bright has given one instance of this, in which no other symptom was present than extensive anasarca with coagulable urine, containing a considerable quantity of the red par- ticles of the blood. The anasarca disappeared under the treatment which was adopted, but the patient died suddenly from inflammation and oede- ma of the glottis. Dissection appears to have proved that in this instance the kidney was in a state of excessive congestion, if we may not go so far as'to call it inflammation. A peculiarity in patients suffering under this dropsy is their extreme liability to be affected by calomel. Dr. Bright and Dr. Gregory have re- lated instances illustrative of their proneness to severe salivation from very small quantities of mercury, and we have ourselves witnessed cases of the same kind. Much importance is attached by Dr. Bright and the Edinburgh physicians to the coagulability of the urine, as indicating extensive change in the structure of the kidney,—much more, indeed, than it appears to us the evidence afforded is able to sustain. Dr. Wells has long ago shown that this symptom appeared and disappeared under circum- stances in which it could not fairly be regarded as the consequence of organic disease. He saw it suddenly induced by the exhibition of mercury : he knew an individual in whom it appeared pro- bable that the coagulability of the urine had ex- isted for nine years: he also pointed out the fre- quency of its occurrence in that form of dropsy which succeeds scarlatina; and showed, likewise, that with the disappearance of the dropsy the kid- neys ceased to pour out serum. Dr. Bright him- self contends only for functional disease in the first instance, leading secondarily as in other cases to organic disease ; although it must be confessed, from the great stress which he lays upon this one symptom, a cursory reader might easily mistake his meaning. Dr. Elliotson, also, is reported to maintain that the urine may strongly coagulate for a time without any change inthe structure of the kidney. We are, however, disposed to go even farther than this; and without denying that in some instances coagulable urine is the consequence of serious primary disease in the kidney, nevertheless to maintain,—that in many instances it is merely a symptom very remotely connected with organic alteration in the kidneys. As a secreting organ, the kidney is especially liable to be affected by the removed by appropriate treatment.it returns again, ! pabulum afforded it; and should the blood reach each time increasing the disorganization of these j it in an imperfect state, whether m consequent 708 DROPSY. of indigestion, imperfect change in the lungs, or inordinate action of the heart, or insufficient ner- vous influence, we may expect that its function will be impaired. Accordingly we see it deposit yellowish sediments in indigestion, lateritious sedi- ments in febrile diseases, and phosphates after injury of the spine. Now in very many of the cases, perhaps in the majority, of dropsy with coagulable urine, the effusion is preceded by inflammatory symptoms of the organs of respira- tion ; and in many there is disease of the heart. Considering the important changes that take place in the bloodjluring its passage through the lungs, we can hardly be surprised that an affection of these organs should influence the secretion of urine; and again, while apoplexy is distinctly traceable to hypertrophy of the heart in some cases, it surely is not extraordinary that by this organ also the secretion of the urine should be modified. But we are not left only to theory on this point: the numerous cases in which the urine coagulates, already referred to, and in which organic disease cannot fairly be presumed to exist, confirm to a certain extent this view of the subject, while mor- bid anatomy still farther corroborates it. In two instances which we have lately had, an opportunity of examining, where the urine had strongly coagu- lated during life, no disease whatever was observa- ble in the kidney. To one of these we have already referred. The other occurred in a lady who had been suffering from pulmonary symptoms, and symp- toms of disease of the heart, for nine months, when we first saw her. At this time the urine coagu- lated strongly, and continued to do so till the period of her death, three months afterwards. Yet, while the left lung, the pleura, and the heart, ex- hibited serious disease of long standing, and while the liver was also diseased, though in a slighter degree, — there was no appreciable change what- ever in the substance of the kidneys. A small cyst containing a colourless fluid was seated on the superior convex portion of the left kidney, but did not in the slightest degree interfere with its structure. In this case there had never been any pain in the back. The view we now contend for is by no means unimportant as a guide to practice; for the plan of treatment must necessarily be different, accord- ing as we consider the kidney primarily or seconda- rily affected. Should we find reason to believe that the respiratory organs are the earliest and principal sufferers, our chief attention must be paid to them. As a guide also to a correct prog- nosis, this view is most important; because, if the kidney is to be regarded as organically diseased in every case of coagulable urine, all such cases would be evidently hopeless, and little would re- main for the physician but to smooth the path to a fatal termination. The next question which presents itself con- nected with this state of the urine, is the condition of the system in which it exists. Dr. Blackall regarded it as inflammatory; Dr. Prout regarded it rather as proceeding from irritation than inflam- mation, (Prout on the Urinary Organs, first edit. p. 48); and other authors appear to have paid scarcely any attention to this part of the subject, excepting so far as stating that it could not be relied upon as a guide in practice. That it is at j times connected with an inflammatory state of the kidneys, the following case, which occurred in our I practice several years ago. abundantly proves. A girl, twenty-three years of age, applied on the 11th of July, 1823, complaining of severe pain across the back, in the region of the kidneys, with shivering and frequent sickness. A short time before, the right foot had swrelied; but at the time I of her application this had subsided. Her urine was of a dark brown colour, depositing a thick precipitate upon the addition of tartarized antimony, and becoming of the consistency of melted butter by boiling. She made water very frequently, but j very little at a time. She complained of pain in the pudenda. The catamenia were scanty, but regular to the period. She had had scarlet fever six months before, and her urine had been of the dark colour, now mentioned, ever since, but occa- sionally becoming a little clearer. This case was regarded as inflammation of the kidneys, and treated accordingly, and on the 21st of July, she was convalescent; the urine had then returned to a healthy state, bring lighter in colour, and afford- ing no coagulum upon boiling. On the other hand Dr. Blackall has given a case of dropsy after scarlatina, in which-the urine remained coagulable after the effusion had disappeared, and regained a healthy state under the administration of cinchona. At the present time we have a case of dropsy with coagulable urine, in which the quantity of serum greatly diminished for a few days after taking sul- phate of quinine.* Dr. Bright also remarks that occasionally we find anasarca even with coagula- ble urine so marked by debility that tonics and steel give decided relief. Dr. Wells had seen the urine become coagula- ble after the exhibition of mercury, and this is now a well-known effect of mercury. Dr. Bos- tock observes that in a great majority of cases of persons in apparent health, serum may be detected in the urine by the appropriate tests, and that in his own person he had observed it to be increased to a considerable amount by the slightest causes. In a patient of the Birmingham Hospital, who had had anasarca connected with bronchitis, after both diseases had disappeared, and the urine, which had originally been coagulable, had recovered its healthy condition, it was found one day immedi- ately after dinner to be rendered almost solid bv heat, and the next morning the same means did not detect a single particle. These few facts abundantly confirm the opinion of Dr. Prout, that taken alone "as a symptom, the albuminous urine does not, in the present state *The patient here alluded to was in the Birmingham Hospital, and died soon after the ahove was written. The body uas examined, but there was no alteration in the structure of the kidneys. The cortical part was paler than usual, but retained its natural structure, and the tubuli were perfectly distinct. The kidneys were exhi- bited to several of the medical ollicers of the establish- ment, who all agreed that there was no change whatever of structure. The liver in this case was, if anything, smaller than natural, and externally had exactly the appearance of lung; internally it appeared as if it were pervaded by inspissated bile, and was firmer than na- tural. The peritoneal coat had contracted numerous adhesions with ihe diaphragm. The heart was remarka- bly small, the walls of the right cavity were very thin, while those of the left compared with the rij;ht were cnornu.usly thick. These were the only unusual appear- ances about the body. This man had been a spirit- drinker. DROPSY. 709 of our knowledge, indicate the use of any parti- cular remedy or mode of treatment; but that, nevertheless, ,t is a symptom of which we ought always to be aware, since, taken in conjunction with the others, it may be occasionally useful in directing us to form a more correct judgment of the general nature of the disease." Albuminous urine appears to be much more intimately connected with anasarca than with as- cites. Dr. \\ ells found it, in twenty-four cases out of thirty -seven, connected with anasarca ; in fourteen cases of ascites previous to anasarca, there was no serum in the urine; and in eieht cases of anasarca subsequent to ascites, the urine in all contained serum, and in one it was rendered solid by heat. Of the seven cases related by Dr. Christison, anasarca was the principal form of dropsy in six, and in the seventh only was the ascites a prominent symptom. Much the same proportion is observable in Dr. Gregorv's cases; snd in the twenty-three cases recorded by Dr. Bright, anasarca was the form of effusion in all. We cannot dismiss this part of the subject without some observations on the composition of coagulable urine. Dr. Bright believed that the dark brown colour was frequently owing to the presence of the red globules of the blood, and in this opinion he is supported by Dr. Gregory. The case of inflammation which we have already given strongly supports this view, and there are few physicians probably who will doubt the possibility of its occurrence. This point therefore we may now leave : a much more important part remains, viz. to afford our readers the best means of inves- tigating some of these points themselves. All the writers referred to (and in numerous instances we have confirmed the fact by our own experience) state that coagulable urine has a much less specific gravity than healthy urine ; and Dr. (iregory has given two tables containing the result of an equal number of trials with coagulable and with healthy urine. The average specific gravity in fifty cases was in healthy urine 1022-46, the highest being 1033, and the lowest 1005 ; while in the coagulable urine, the highest was 1023-5, snd the lowest 1006-5. With regard to the best means of detecting al- bumen when it exists in urine, we may observe that heat, while it is of readiest application, will irenerally be found sufficient. It is often advisa- ble, however, to make use of re-agents, and of these corrosive sublimate is the most delicate. The nitric and muriatic acids are also employed for the same purpose, as is also the ferro-prussiate of potash, and alcohol. With respect to the effects of these latter re-agents, Drs. Gregory and Bos- tock are somewhat at issue. The former says hat he never knew a case in which they caused i precipitate when heat had no effect, while Dr. Bostock observes, " I have also found certain states of the urine where heat had no effect, hut where muriatic acid threw down a precipitate, and scjaiii where muriatic acid had no effect, but where the albumen was detected by the bichloride of mercury, or the ferro prussiate of potash." All, therefore, that can be deduced is, that all these re-agents should be employed in succession in suspected urine, when the first fails to discover albumen. 3k Dropsy from Disease of the litems and Ovaries.—Many of the affections of the uterus. after they have existed long, give rise to dropsical effusions into the lower extremities. Sometimes this appears to be the result of pressure only upon the great vessels, when ihe uterus is either en- larged itself or contains a tumour of considerable size. At other times the effusion appears to be the result of the hemorrhage to which, under cer- tain forms of disease, the uterus is peculiarly lia- ble. This therefore is not fairly to be referred for its origin to organic disease of the uterus ; th« dropsy is simply the consequence of the hemor- rhage, and hemorrhage from any other organ would give rise to similar results. With regard to the ovaries, we know that they are themselves the seat of those affections which are called en- cysted dropsies, and in this light they do not at present demand our consideration. But affections of the ovaries appear sometimes to produce real ascites, while they still present only the character of nearly solid tumours, and at the same time the lower extremities become oedematous. We have already mentioned our suspicion that ascites is sometimes a consequence of ovarian disease, sub- sequent to parturition, and we have met with cases of bronchitis in which ascites has taken place earlier than probably it would have done, had not ovarian disease existed previously. Morbid Anatomy* — This naturally divides itself into two parts :—first, the morbid anatomy of the serous membranes and cellular tissue, which arc the immediate sources of the effusion ; and, secondly, the morbid changes of the various vis- cera, in consequence of which the serous mem- branes and the cellular tissue assume a dropsical disposition. 1. The most ordinary appearance in the serous membranes is thickening and opacify, which are more or less manifest in every serous membrane of the body. Thus in hydrocephalus, the lining of the ventricles, though seldom separable as a membrane, is evidently firmer and more condensed than natural; but the changes referred to are much more easily seen in the pleura, pericardium, and peritoneum. All these membranes become. opaque or thickened ; coagulable lymph is thrown out; and we not unfrequently find large layers of lymph converted into factitious membranes. Ta- cheron (Recherches Anatomico-Pathologiques, vol. iii. p. 196) says, "The pleura has been found thickened and covered with a layer of villous mat- ter, oily to the touch, whitish, and similar to the intestines of the cow when converted into tripe." The same author has given an example of both pleura and the peritoneum becoming tuberculated. Dr. Ayre has related a case of ascites in which he found the peritoneum thickened and opaque, quite white, and having nearly the thickness of chamois feather. In the Quarterly Review of Foreign Medicine, a case is given of a woman who became dropsical after being brutally kicked by her hus- band : in thirteen years she was tapped 665 times, and on dissection the peritoneum was found car- tilaginous and three lines thick. So far as the serous membranes themselves are concerned, these appear to be the principal changes. With respect to the cellular tissue, Portal tells us that in dropsy it is more or less thickened, thai 710 DROPSY. the cells are dilated, and many converted into one, and that he had seen the intermuscular cellular tissue put on a cartilaginous appearance under such circumstances. (Portal, Des Hydropisies, tom. ii. p. 12.) Morgagni relates a case of anasarca in which the tissue was thickened, and, as he says, the fluid, from the frequent intervention of the cellular layers, assumed the likeness of ge- latine. Bichat observes that in prolonged cases of leucophlegmasia, the subcutaneous fluid is by degrees infiltrated through the prolongation of the areolae of the skin, separates their fibres, and some- times penetrates to the epidermis, which it bursts in different places, and the fluid escapes through the apertures which are thus made. (Bichat, Anatomie Generate, p. 689.) In the case above referred to, from Morgagni, the cuticle had been thus raised, but not burst, so as to form immense bladders, which were filled with water. (Mor- gagni, Ep. xxxviii. c. xxvi.) The cellular tissue itself is in such cases remarkably bleached. This perhaps is the proper place for noticing the changes which occur in the absorbent vessels and veins. It has been often assumed that the former may be dilated and burst, but we know no cases which afford confirmation to such an opin- ion. That the absorbent vessels are more easily detected in dropsical bodies is true, but this pro- bably is chiefly owing to the removal of the adi- pose substance of the system. Dr. Hodgkin, how- ever, has lately rendered it probable that these vessels are in some way connected with effusion. He has related several cases of dropsy in which the absorbent glands, and especially those sur- rounding the great vessels, were enlarged and in- durated. (Medical Gazette, January 21, 1832.) This enlargement appears to consist throughout of an uniform texture, rather the consequence of a general increase of the whole gland, than a new structure displacing the original one. It is simply an hypertrophy therefore of the glandular system. In illustration of this morbid growth, five cases are given, two in children, one nine and one ten years old; one in a man aged thirty, and two in persons of fifty years of age. In four of these cases the spleen was enlarged ; and a fifth case of enlarged spleen with general induration of the absorbent glands is referred to, drawings of which were made by Dr. Carswell, and are contained in his collection. In local anasarca the veins frequently exhibit peculiar appearances. Sometimes their cavities are completely obstructed by fibrinous clots, which have evidently formed during life. In other cases the internal membrane is thickened, red, and co- vered with coagulable lymph. Occasionally pus is found in their cavities. Diseases of the arteries are often found in dropsy, and particularly aneurisms of the aorta. The late Mr. Freer believed that inflammation of the lining membrane was common. We are not aware that this observation has been confirmed, but we have seldom opened a patient dying with general dropsy who did not exhibit some disease of this mem- bianc. This generally consists of scrofulous or buny deposits, with frequent ulceration ; and we once saw the descending: aorta beset with nume- rous incipient aneurisms, from this cause, a few of them being larger than a good sized pea. 2. The lungs are frequently found with the appearances consequent to bronchitis. The bron- chial membrane is inflamed, and its texture thick- ened, sometimes even ulcerated. The cavities of the bronchi and air-cells are filled with a frothy fluid, and sometimes with pus. At other times we find the common results of pneumonia, con- gestion of the lungs, serous infiltration, hepatiza- tion, purulent infiltration, &c. When dropsy of the pleura has existed long, the lung is often so much compressed as to form a solid body, wholly or in part impervious to air. Tubercles are not unusually discovered in drop- sical patients, although no suspicion of tubercular phthisis may have existed during life. The various organic alterations of the heart are also frequent in this disease, and may, doubtless, be regarded as the original cause of effusion. For a more minute account of these morbid changes we refer the reader to the articles on the diseases of this organ. The liver exhibits an immense variety of ap- pearances in dropsy. It is sometimes hard and scirrhous, many instances of which are given by Morgagni. (Epist. xxxviii.) Dr. Baillie says in many cases of ascites the liver te diseased, being hard and tuberculated ; and in another place he has particularly described the kind of change which is here meant. The tubercles which are formed in this disease occupy the whole mass of the liver, are placed very near each other, and are of a roundish shape. They give an appearance everywhere of irregularity to its surface. When cut into, they are found to consist of a brownish or yellowish-white solid matter. They are some- times of a very small size, so as not to be larger than the heads of large pins; but most frequently they are as large as small hard nuts, and some- times larger. When the liver is thus tuberculated, it feels much harder to the touch than natural, and not uncommonly its lower edge is bent a little forwards. Its size, however, is not generally larger than in a healthy state, and sometimes Dr. Baillie thought it was smaller. If a section of the liver be made in this state, its vessels seem to have a smaller diameter than they have naturally ; and it frequently happens that the liver is of a yellow colour from the bile being accumulated in its sub- stance. The gall-bladder is generally contracted, and of a white colour, from its being empty. Dr. Baillie also mentions a peculiarly hard liver, which exhibits, when cut into, no peculiar structure, and is also accompanied by incipient ascites. This state of the liver has frequently fallen under our notice, and we have found it still only unusually firm when the ascites has been very considerable. Dr. Bright has described an appearance of the liver, probably the more advanced stage of the last morbid structure, and which seems really to de- serve the name of scirrhus. The substance of the liver is hardened throughout, and bands of thick- ened cellular membrane, like ligamentous matter, pervade every part: in some parts of the liver from which this description is drawn, it formed one-third of the whole structure. Although, when seen externally, the liver appeared tuberculous DROPSY. 711 and knotty, yet when examined internally there were no tubercles. The liver is also sometimes studded with large white tubercles ; and we have seen the structure of the organ so completely ob- scured by their accumulation, that it could scarcely be recognised. This disease, however, seldom gives rise to effusion till it has made very exten- sive progress. The weight of the liver in such cases is often very great : in a patient whom we examined last year, it amounted to eleven pounds. The changes now enumerated form indeed but a small part of the modifications to which this organ is liable, and which are found to give rise to effusion. The observation of Dr. Bright, how- ever, that those changes in the structure of the liver by which the branches of the vena portae are compressed more frequently give rise to dropsy than any of the circumscribed changes, (as tuber- cles of various kinds, and hydatids occurring im- bedded in their substance,) is perfectly accordant with our own experience ; and the observation we have just made respecting the period of effu- sion in tubercular disease of the organ, drawn as that observation is from numerous facts which have fallen under our notice, is an additional confirmation. The colour of even what is called a healthy liver is exceedingly various, and hence, from colour alone, it is not easy to draw any positive conclusions. Sometimes, however, the variation is so decided that we cannot hesitate to pronounce the structure diseased. The most remarkable of these changes is that which has been termed the nutmeg liver, and this term more completely ex- plains the appearance than any lengthened descrip- tion can do. Sometimes the whole liver is much lighter than usual; at others it is yellow, and ap- pears to be filled with inspissated bile; and Dr. Bostock has rendered it probable that this is ac- tually the case, for in a liver of this kind submitted to his examination, he inferred from numerous experiments that it contained cholesterine, the substance which forms the basis of biliary calculi. In a liver which we examined within these few days, the colour externally was that of hepatized lung, and it might easily have been mistaken for this organ so far as the colour was concerned. The interior was very dark, yet we could scarcely say that the structure was diseased. [See Liter, Diseases of the.] The spleen is also frequently found in a diseased state in dropsy. It is sometimes much harder than natural, and at the same time considerably en- larged. It will occasionally attain an enormous bulk, forming a very prominent tumour in the abdomen, and after continuing some time, giving rise to effusion, by which the tumid spleen is sub- sequently concealed. The structure of the spleen does not'in such cases appear altered, but is only firmer and more compact, still retaining its natural colour arid granulated appearance. Sometimes this organ is covered with small white cartilagin- ous bodies, probably tubercles, as we once found them in a man whose lungs were studded with similar particles ; and Dr. Hodgkin has related a case in which they seem to have pervaded the substance of the organ. In this instance the spleen was at least nine inches long, five broad, and pro- portionably thick : its structure consisted of an | almost infinite number of small white globules, which appeared to arise from deposits in the cellular tissue of the organ. The pancreas is seldom diseased in dropsy; we j have sometimes thought it much harder than natural, but on cutting into it it has invariably exhibited a natural structure. The kidneys are subject to various diseases, and very different morbid structures are exhibited in them in cases of dropsy. Dr. Bright thinks that his investigations will authorise three varieties generally attended by albuminous urine; — "In the first a state of degeneracy exists, which, from its appearance, might be regarded as marking little more than simple debility of the organ" (anaemia). " In this case the kidney loses its usual firmness, becomes of a yellow mottled appearance exter- nally ; and when a section is made, nearly the same yellow colour, tinged with grey, is seen to pervade the whole of the cortical part, and the tubular portions are of a lighter colour than natu- ral. The size of the kidney is not materially altered, nor is there any obvious morbid deposit." This state of the kidney is well known as the consequence of dram-drinking, but it certainly is not confined to the victims of intemperance. It is frequently found in patients who have suffered from tedious and exhausting disease; and Dr. Bright himself states that he had observed it in a case of diarrhcea and phthisis, and of ovarian tumour. We have observed it in a woman who died from disease of the heart, and in whose lungs there were softened tubercles, none of which had been discharged. In this instance the urine did not afford the slightest coagulation by heat. In the most advanced stage of this disease Dr. Bright thinks that there is a more decided alteration of structure, and that some portions are consolidated so as to admit of very partial circulation; in which state the surface has a somewhat tubercu- lated appearance, the projections being paler than the rest, and at this period the urine is coagulable. The second form is one in which the whole cortical part is converted into a granulated tex- ture, and where there appears to be a copious morbid interstitial deposit of an opaque white substance. In its earliest stage this only produces externally an increase of the natural mottled appearance, or sometimes that of fine sand sprin- kled more abundantly on some parts than others. The same appearance is slightly observable inter- nally on making a longitudinal section. After the disease has continued some time, the deposited I matter becomes more abundant, and innumerable specks of no definite form are observed on its I surface. The cortical part exhibits, on being cut into, a similar appearance. Later in the disease, the granulated state begins to show itself exter- nally in frequent slight uneven projections on its ! surface, and the kidney is rather larger than natural. In the third form the kidney is quite rough and scabrous to the touch externally, and rises in numerous small projections, yellow, red, and pur- plish. The organ is often inclined to be lobulated, and on making an incision, the texture is found approaching to cartilaginous hardness. The tubu- lar portions are observed to be drawn nearer to the surface, and it appears like a contraction of every 712 DROPSY. part of the orjran, with less interstitial deposit than in the last variety. Dr. Bri-jht also mentions two other conditions of the kidneys, in which coagulation of the urine is sometimes observable. One of these consists in a preternatural softness of the organ; the other in the blocking up of the tubular structure by small portions of a white deposit, bearing the appearance of small concretions. In the former, a corresponding loss of firmness has been observ- able in the heart, liver, and spleen ; and in the latter, the cortical portion has been firmer than usual, and the tubuli have assumed a waved direction. These are by no means the only diseases of the kidney that give rise to or are attended by dropsy. It is sometimes scrofulous. We have seen it con- verted into a steatomatous tumour so large that it formed a prominent tumour in the abdomen. In another case the right kidney was five or six times its natural size, soft, and divided into lobules. On opening it, it was found full of scrofulous matter, which occupied the whole of the cortical part and the interstices of the tubuli, which were scarcely at all traceable. The left kidney equalled the right in size, but was less diseased. The cortical substance was changed into a granulated fatty substance, presenting much the appearance of the liver under some circumstances. The tubuli were in this instance quite distinct. In this case, which is copied from notes taken in 1826, the urine had come away stillatim, and the patient had suffered very much from excoriation of the pudenda. She never complained of any particular pain till six weeks before her death, when she became anasar- cous. The symptoms then agreed with those of Dr. Bright's and Dr. Gregory's cases. From the urine during the whole period coming away stilla- tim, this secretion was not particularly examined. We have particularly mentioned this case because it illustrates the remark of Dr. Gregory, that the persons in whom he found the morbid alterations of the kidney, were either those who had led irregular lives, or who presented the usual charac- ter of the strumous diathesis. Again, in a case which we examined a few days ago, the left kid- ney contained several calculi; and its structure, though much wasted, was remarkably healthy in appearance*, while the right kidney was pale, and the tubuli were very indistinct in consequence of an interstitial deposit of a whitish substance. These, probably, are only a few of the devia- tions from health which occur in the kidney, and which give rise to or accompany dropsy. With regard to any of these changes being necessarily connected with albuminous urine, enough has been shown above to prove that at present the subject requires additional investigation. We hive found albuminous urine to a very considera- te extent, without any corresponding alteration in the structure of the kidney ; and we have related one instance of Dr. Bright's first variety, in which the urine did not coagulate. It cannot, however, >•> considered improbable that this phenomenon is "»isnccted with some peculiar condition of the organ, and that, when long continued, it will lead to 6ome peculiar morbid alteration of structure. But what this condition or this alteration may be, must still be regarded sub judice; and we should mislead our readers in no slight degree if we called upon them to believe that anything further in this matter has yet been discovered, than a more fre- quent coincidence between coagulable urine and disease of the kidney than had been previously suspected. This coincidence, though frequent, is not invariable; nor are the symptoms which are reported to indicate it more to be relied upon. [See Kidnet, Diseases of the]. Prognosis* — The prognosis in dropsy must naturally vary much according to its origin, its combination with organic disease, its duration, and the debility of the individuals who are the subjects of it- Acute dropsies, cseteris paribus, are more curable than chronic, and idiopathic are more curable than secondary dropsies. With regard to acute drop- sies our judgment must be greatly guided by the concomitant circumstances. If there be any vital organ seriously affected, us the lungs or the heart, our chance of removing the effusion will be governed greatly by the control we may be able to obtain over the original disease. Thus, if anasarca succeed bronchitis, a permanent recovery from the dropsy cannot be expected without the disappear- ance of the bronchitis. It will indeed sometimes happen, as we have mentioned in a previous part of this article, that effusion will disappear a short time before death; but this clearly is no cure of the secondary disease. In healthy constitutions, which have been uninjured by irregular habits of living, the acute dropsy will, under proper treat- ment, usually terminate favourably; but in those who have been weakened by drinking or other irregularities, or who are originally of debilitated constitutions, we can seldom venture to predict recovery. With regard to secondary dropsy, we may state that those arising from disease of the heart usually admit of removal, but the disappearance of the effusion is seldom permanent. Nevertheless, longer or shorter intervals of ease are afforded; and, under cautious treatment, months, and even years may elapse between the first occurrence of effusion and the fatal termination. The same remark to a certain degree holds good of that species of dropsy which accompanies disease of the lungs, but it is certainly less curable than the former specfe-s. The effusion which succeeds hepatic disorders is almost always fatal, and by no means affords a chance of cure in an equal degree with the two former modi- fications. There are, however, some cases of ascites connected with enlargement of the hver, in which the effusion will disappear repeatedly under the use of diuretics, and in a few instances we have known a considerable time elapse before it has returned. That which succeeds or is accom- i panied with extensive disease of the kidney seems j absolutely incurable when the renal disturbance has produced any extensive change of structure; j but the symptoms of this change are by no means at present satisfactorily ascertained. Treatment.— In the treatment of dropsy, as in every other disease which falls under the care of the physician, certain general principles are first J to be considered; and, secondly, the circumstances by which these principles are more or less modified. I It has already been stated that dropsies are l sthenic or asthenic, or in different periods of their DROPSY. 713 progress that they partake, of both conditions—at one time the sthenic, at another the asthenic pre- dominating. To this point, th™, attention must first be paid, and an antiphlogistic or a contrary regimen pursued accordingly. Should the effusion have arisen suddenly, and should local inflammation be present, whether of the lungs or any other organ, bleeding must by all means be recurred to; and it must be carried far enough to affect the system, to reduce the pulse, produce feintness, or relieve the immediate inflammatory symptoms. The bleeding may be repeated should the in- flammation continue, and should the strength of the patient permit. But even when this is much reduced, and venesection can scarcely be justified, local bleeding may be advantageously employed, and in all such cases cupping is much more effica- cious than leeches. The glasses should be applied as near as may be possible to the affected organ, and to the part of the organ which is most impli- cated. Accordingly, in disorders of the lungs, the blood should be drawn from the region of the chest; and if, which will frequently occur, one part of the organ is particularly affected, the glasses should be applied opposite to it. The same remark holds equally good in dropsy connected with in- flammation of the pleura. In this case the chest should always be examined without covering, for by its dilatation, contraction, &c, much additional assistance is afforded to the diagnosis. Next to bleeding, counter-irritants are indicated in all those cases in which there are local affections, and it may be necessary to continue these for a considera- ble time. Indeed, in all chronic disorders, if counter-irritation be advisable at all, it is advisable to persist in it, either till the disease for which it is employed has disappeared, or till the strength of the patient seems to suffer from its effects. Who- ever has examined a dropsical patient when pleu- ritis has been present, must have remarked the presence of factitious membranes of very different ages, and in comparing them with the previous symptoms he will usually be able to fix upon pre- cise periods at which some of them were first formed. A little further reflection will lead him to the conclusion that at no time had the tendency to pleuritic inflammation been completely over- come, and although, at particular stages, evident and very severe exacerbations had taken place, yet that through the whole disease the inflammatory action had more or less persisted. Under such circumstances, reason clearly points out one course, viz., to continue the remedy while the slightest trace of inflammation remains. In inflammation of the pleura, (perhaps of serous membranes gene- rally,) this is particularly necessary, for it is not always painful, and may proceed a great way without exciting surprise. And it is this point that appears to us most important in that species of dropsy to which Dr. Bright has assigned the morbid state of the kidney for its origin. We have already expressed our doubts whether in the majority of such cases the inflammation of the serous membrane be not the primary disease; at any rate it is frequently concomitant, and in no slight degree accelerates a fatal termination. Under such circumstances it is to the local inflammation and not the effusion that attention must be paid; Vol. I___90 3k* if the former continue, the disappearance of the latter will be of no avail. Bleeding is not only called for in dropsy when local inflammatory symptoms are present; a general state of plethora equally demands it. Our chief dependence for an accurate diagnosis in this case is the full hard pulse, and in great measure also the history of the patient. We cannot, however, too strongly inculcate the necessity of care in bleeding indi- viduals of irregular habits, and who have indulged excessively in drinking, especially spirit-drinking, or in any other debilitating vice. Whatever may be their appearance, or however hard and firm their pulse, such persons ill bear extensive san- guineous depletion ; they sink rapidly afterwards into a low typhoid state, without the possibility of rousing the system to healthy and energetic action. Of the two principal modes of overcoming in- flammation, bleeding and counter-irritation, we have perhaps for this place said enough. Of in- ternal remedies, the two most powerful unques- tionably are the antimonium tartarizatum, and calomel in combination with opium. The former, to be really serviceable, should be administered in the doses recommended by the Italian physicians, and thus given, its efficacy in inflammation is most extraordinary. Nor is its effect merely felt in depressing the inflammatory action; it acts upon the bowels and upon the skin, and thus, not unfrequently, by promoting the functions of these organs, but especially of the last, it favours even directly the removal of the effusion. The princi- pal inconvenience which is experienced from this medicine is the nausea and sickness which it in- duces, particularly after the first few doses. This, however, in most cases soon disappears, and the patient is able to take from one to three or even four grains at a dose without the slightest nausea. It will indeed occasionally happen that an indi- vidual cannot obtain what has been well termed the tolerance of the medicine; this, however, is so rare a case that it does not contradict the gene- ral position. Calomel and opium have been long known as peculiarly useful in those inflammations which throw out plastic lymph, such as iritis, cy- nanche laryngea, &c. These, however, are by no means the only forms of inflammation in which calomel and opium may be advantageously sub- stituted for venesection or any other mode of bloodletting. Whenever the strength of the pa- tient is too much reduced to admit of farther san- guineous depletion, while still the inflammatory symptoms continue unsubdued, this combination may be usefully employed. It should be given as frequently as every three, hours, and according to the age of the patient the dose may be proportion- ed from two to four grains of calomel, with from half a grain to two grains of opium, every time. It may be continued till the mouth becomes slight- ly affected, but it will be seldom advisable to carry it farther than this. What has been now said merely refers to the subduing of any inflammation which may be present, which may give rise to or accompany the dropsical effusion. But to these we may often add diuretics or purgatives. Of the different articles which are employed for this pur- pose we shall speak more particularly in a subse- quent part of this article. We here only inti- 714 DROPSY. mate that in addition to the plan for overcoming any local inflammation or general plethora, we are also called upon to attempt the removal of the effusion by stimulating the secretions of the bow- els and kidneys. While on the one hand we frequently find drop- sical effusion united with inflammation, so on the other the system is sometimes, though perhaps more rarely, in a state of general debility. In this last condition a very opposite practice must be adopted, and the most powerful tonics, such as quinine and the different preparations of steel, may be not only safely administered, but may even be demanded. We must not, however, for- get that mere weakness will not justify the use of these remedies, because this may and frequently does occur when local inflammation is present. A greater object will therefore be to distinguish these different states; for what will be useful to the one will unquestionably be injurious to the other. For the diagnosis we must refer to the histories of dropsies as we have laid them down in the present article, and under Ascites and Anasarca. When, after proper investigation, we are fully satisfied that the system is in a state of great general debility, the sulphate of quinine and the different preparations of steel may be given. It will, however, often happen that a de- bilitated patient cannot bear such powerful tonics, and that their stimulating power produces fever- ishness and general irritation. In this case we may have recourse to the vegetable bitters, and if the patient is very feeble, the Iceland moss will he found to be one of the most useful remedies which the Materia Medica affords. Between these two plans, however, we may be called upon to take a middle course, and alternate- ly to depress and support the strength of the sys- tem, accordingly as inflammatory symptoms or the reverse predominate. Here reliance must be placed upon the judgment of the medical atten- dant. Under such circumstances local depletion will generally be much preferable to general, and the peculiar symptoms will generally point to the affected organ. We have already stated that cup- ping, when it can be effected, is to be preferred to leeches, as the quantity of blood taken is more easily ascertained, and far less fatigue induced to the patient. The remarks now made equally apply to every form of effusion, but some modification of treat- ment is peculiarly called for according to the or- gans from which the dropsy derives its origin. It is to these points, therefore, that we now more particularly call the attention of our readers. Treatment of Dropsy connected with Disease of the Hart.—Next to the general considerations which have already been mentioned, we have to recollect that any obstruction in the flow of blood from the right to the left side of the heart will be very likely to produce congestion in the lungs, and for the relief of this symptom we may be call- ed upon merely to diminish the general mass of blood in the system. And again, should the size of the heart be greatly increased, even though no very material disease should exist in the valvul-ir structure of the organ, the lungs may be so com- pressed that they may be unable to receive, with- out inconvenience, even their usual complement of blood; and for this cause also depletion may be necessary. These observations may not ap- pear to bear immediately upon the treatment of dropsical effusions, but without a reference to the organs upon which such effusions depend, it will be impossible in any case to conduct them to a successful termination. Our first attention then is due to the condition of the heart and its influ- ence upon the lungs; our second must be direct- ed to the dropsy itself. In the first place, we must consider whether there exists a sthenic or asthenic state of the ge- neral system. If the former prevails, recourse may be had to drastic purgatives, particularly to elaterium and croton-oil, with or without pre- vious bloodletting, according to circumstances; and in few cases does more good effect follow the exhibition of remedies. They must be repeated every two or three days till the effusion entirely disappears. By this means we must not, how- ever, expect that the dropsy will be prevented from returning; but considerable intervals of ease will be afforded, and the patient may be enabled to live comfortably for several years, the dropsy oc- casionally recurring and being restrained by treat- ment. Some patients, however, ill bear excessive purg- ing, and we are then compelled to use other means, and chiefly diuretics. Of these the digitalis pur- purea, or common fox-glove, is one of the most efficacious in the effusion which depends upon disease of the heart, and which is connected with some degree of debility. In this respect our ex- perience corroborates the opinions of Drs. With- ering and Blackall, that it is most successful where the debility is completely marked, the countenance pale, the pulse weak, and the muscular energy lessened. We have usually preferred the infu- sion, and have administered it in half-ounce doses two or three times a day, till it has increased the urine, had a decided effect upon the pulse, or pro- duced some other of its peculiar consequences. The propriety of giving digitalis in cases of de- bility naturally suggests its use in those cases in which it is necessary to commence the treatment by bleeding ; and accfirdingly this plan was re- commended by Dr. Withering, and has been con- firmed by Dr. Blackall, as probably by most phy- sicians who have paid much attention to the ac- tion of this drug. Dr. Blackall has mentioned one symptom which is decidedly opposed to the exhibition of digitalis, viz. "a membranous ten- sive pain in the head, sometimes over one eye, with a sort of disturbance of the brain, which oc- casionally attends an overdose before any bad signs have appeared ; if neglected, it is followed by convulsions." The same physician also re- marks, very correctly, that when the urine is de- cidedly increased, the digitalis ought to be sus- pended, as its debilitating effects are then apt to become greater than the system can bear with im- punity. The diuretic effect of digitalis is some- times greatly increased by its combination with opium, as indeed is the case with many other diu- retics. Sometimes the dropsy consequent to disease of the heart occurs in such a state of general debili- ty, that somewhat of a tonic plan is required. We have repeatedly seen such a state occur in DROPSY. 715 females, ,n whom there has been either a misera- ble hysterical state, or positive and decided hypo- chondnacism. Active stimulants, it is evident, must be as injurious to such patients as depleting measures; both, though from different causes, will increase the turbulent action of the heart and the distress of the patient. Under these circum- stances we have found great benefit from the fer- rum tartanzatum, either in combination with a tonic or with a diuretic, such as the infusum ge- nista? or the infusum taraxaci ; these appear to strengthen the system generally, while they act powerfully upon the kidneys. In the latter, or rather the last stage of this spe- cies of dropsy, the anxiety, or we might say the anguish of the patient, is inconceivably painful to witness. Often the mind remains unclouded, and all the natural feelings of affection for rela- tives, and attachment to life for their sake, re- main unimpaired. When the disease has attain- ed this point, it is only in our power to afford temporary and very imperfect relief by means of opium and ether. These must be given in fre- quent doses, and large enough to ensure their specific effect. Fortunately, painful as is the stage we are now considering, it does not last long; the patient shortly falls into a state of stu- por, and sleeps, as it were, to death, or dies in- stantaneously, and very unexpectedly to the at- tendants. Treatment of Dropsy connected with Disease of the Lungs.—On this form of dropsy we have not much to add to the remarks which we have just made with regard to the effusion when con- nected with disease of the heart. Bleeding, gen- eral and local, may be and frequently is necessary; and, in addition to this, counter-irritation, espe- cially by means of the tartrate of antimony, ought strictly to be enforced. With respect to medicine more immediately calculated to remove the effu- sion in this as in the preceding form of dropsy, we are chiefly dependent upon purgatives and diuretics. With regard to the former, they ought never to be exhibited while we suspect the lungs to be the subject of inflammation. It is, we be- lieve, a remark of Sydenham, that violent purga- tives are injurious in pneumonia, and we have had frequent occasion to confirm the opinion. When, however, effusion is present in the chest or in the lungs, without any sensible inflammatory state, the drastic purgatives frequently afford the most remarkable relief, and sometimes suffice alone for the entire removal of the dropsy. As a diu- retic, digitalis appears less serviceable in dropsy consequent to disease of the lungs, than where the heart is the original seat of disorder. Squills, however, in combination with laudanum and the neutral salts, particularly the sulphate of magne- sia, act very powerfully upon the kidneys, and in some instances speedily and entirely remove the effusion. It is in this form of dropsy that the supertartrate of potash deserves the greatest con- fidence, as it keeps up a constant flow from the kidneys and the bowels together, without inducing that debility which drastic purgatives or digitalis are so apt to occasion. Treatment of Dropsy connected with Disease of the Liver.—This is probably the most difficult of any species of dropsy to treat successfulfy, in consequence partly of the broken-down constitu- tion in which it generally occurs, and partly from the obscurity in which the different diseases to which the liver is liable are involved. When we can satisfy ourselves that this organ is the subject of inflammation, without any remarkable change in its structure, local bleeding and counter-irrita- tion are required in the first instance ; and, in the second place, those internal medicines which are known more particularly to act upon the biliary secretions, such as the different preparations of mercury, and the nitro-murialic acid. Mercurial frictions may also be had recourse to with advan- tage in very many cases. The mercury should be persisted in till the mouth is affected, and bene- fit has sometimes been derived from keeping up salivation for a considerable time. In addition to placing the system under the influence of mer- cury, some medicines are required more immedi- diately to act upon the kidneys, and through their increased action to carry off the effused fluids. In the article Ascites we have mentioned the utility of combining many diuretics together; and in the form of dropsy that we are now considering this practice is more particularly demanded. Among the most efficacious under these circumstances are squill, colchicum, liquor ammonia? acetatis, and the spiritus anheris nitrici, given in combination of two or more, and administered every three or four hours. When, however, the colchicum is given, much attention is necessary that it does not induce its peculiar symptoms, which are pre- cisely those of cholera. This may take place in peculiar constitutions after a single dose only, but more commonly, like digitalis, it accumulates in the system, and its effects are not developed till after the medicine has been continued for several days. Digitalis is not often applicable to dropsy connected with extensive hepatic disease, as its debilitating effects are greater than patients so af- fected can bear. Dr. Fowler made very numerous and satisfactory experiments upon the nicotians tabacum, and why this medicine should so com- pletely have fallen into desuetude it is difficult to determine. It is certainly one of the most pow- erful diuretics which the Materia Medica contains, and we have never seen any evil effects resulting from its use. It has appeared to us particularly useful in dropsy connected with enlargement of the liver and spleen, but little to be relied upon when the principal disease is situated in the chest. The reports of Dr. Fowler are unfortunately not full enough to enable us to draw any very accu- rate conclusions as to the nature of the diseases in which he found it most beneficial; but five of the successful cases in which he used it were the consequence of agues ; and enlargement of the spleen is well known to be a common consequence of this disorder. The form we have used is the infusum nicotian® of Dr. Fowler, which is made by pouring a pint of boiling water upon an ounce of tobacco. This is suffered to macerate for an hour in a covered vessel, and fourteen ounces only are strained off, to which two ounces of rec- tified spirits of wine are added to make it keep. Thirty drops are given at first three times a day in water, and the dose is gradually increased, till it augments the flow of urine, or produces sick- ness and giddiness. The dose has been carried, 716 DROPSY. by Dr. Fowler, as high as one hundred and eighty drops at night, and one hundred in the morning. With the exception of abstaining from mercury, it does not seem necessary to lay down any other plan than what has now been referred to, when the disease of the liver amounts to change of | structure. It ought, however, to be always kept j in mind, that when the liver is tuberculous, or we have reason to believe that it is affected with hy- j datids, mercury may weaken the patient, but can have no effect upon the disease. How far under such circumstances it may be advisable to try iodine, or the muriate of lime, may be very pro- jierly a subject of consideration. In a case of j apparent simple enlargement of the liver, in a girl ; of twelve years of aire, but unconnected with dropsy, we certainly derived great advantage from employing the former, and under similar circum- stances, connected with effusion, we should cer- tainly be inclined to afford it a trial. Treatment of Dropsy connected with Disease of the Kidney.— Dr. Bright, who has most at- tended to this subject, appears to lay the principal stress upon the supertartrate of potash ; but in this, as in every other modification of dropsy, reference must first be had to general principles. We have already stated our opinions at some length respecting the signs by which the affections of these organs may be ascertained. When, therefore, we feel convinced that the kidneys are diseased, the same rules which have been laid down for the treatment of other local disorders will apply here, and local depletion with counter- irritation must be as proper in the one case as in the other. At the same time we confess that on this point we have not experience for our guide, so far as this particular organ is concerned. We may, however, mention a fact that has been related to us on good authority connected with diabetes mellitus, and which has some analogy with the disease now under consideration. The medical man to whom a patient with this disease applied, and from whose urine he had collected a conside- rable quantity of sugar by evaporation, rubbed in the unguentum antimonium tartarizatum over the loins ; and while the irritation was kept up, the sugar entirely disappeared from the urine. Other symptoms, however, supervened, which compelled him to suspend the ointment, and the sugar was again found in this fluid. The supertartrate of potash has the same effect in this dropsy as when disease of the lungs or pleura is present. We are sorry to say that we have little more to add on this subject, as it is one to which at present little attention has been paid, and respecting which our actual knowledge is any thing but pre- cise. We would, therefore, most strongly incul- cate the observance of general principles in its treatment, till farther investigations shall have clearly demonstrated those peculiar modifications of practice which may be demanded by the par- ticular organ. [Observers have differed in regard to the pro- priety of administering diuretics in the dropsy occasioned by the disease of the kidney, described by Dr. Bright. By most, they have been con- sidered unadvisable, especially in the early periods; but they are advised by M. Rayer, who prefers cochleariu arraoracia. Notwithstanding the argu- ment of Dr. Christison (On Granular Degeneration of the Kidneys.Eiiinb. 1S39, and Philad. 1839, and nrt. Granular Diseases of the Kidney, in Tweedie's Library of Practical Medicine, Amer. edit. iii. 271: Philad. 1842) that an agent which increases the secretion of an org,.n may not add to existing disease in that organ, diuretics must be considered equivocal remedies; and, upon the whole, Dr. Christison is desirous of so regarding them in the disease under consideration ; but he is of opinion, that the "dread of an ewl influence from them over the primary disease has led several estimable authorities to forbid their employment likewise in all secondary affections, in some of which no otlier remedies are so promptly efficacious."] We may here very properly terminate our con- sideration of particular forms of dropsy. They, however, by no means exhaust the subject; and careful observation would probably find signs no less marked in effusion occurring after the disease of other organs, and a consequent propriety of modifying the treatment. What we have already said will, we trust, afford a somewhat clearer view of the principles upon which dropsy ought to be treated, than has yet been published. It will show that certain general principles apply to all, but that these are more or less modified according to particular circumstances, and the organs which give rise to effusion in the first instance, or become involved in the course of the disease. There is nothing empirical or irrational in this treatment. Dropsy is not (as it is too often regarded by men even highly intelligent and much engaged in practice) the consequence either of debility alone or inflammation alone; it is neither always a sthenic nor asthenic state of the system in which it occurs; it may be one or the other, or the one may alternate with the other. Since we find that different organs are the original causes of effusion, the treatment of the local diseases is not to be neglected in the great anxiety to remove the dropsy. Neither is effusion to be neglected ; but we are to use different remedies according to the organs which are affected. Some of these we have endeavoured to point out; in doing so we do not pretend to be free from error ; but the road is opened for others, to pursue a similar line of observation. If this is carefully followed, we do not question but that a few years will add a mass j of" information respecting the peculiar power of medicines in this disease, which may go far to diminish its present ill repute, as one of the opprobria raedicina?. Of the particular remedies employed in Dropsy.—We should not consider that we com- pleted the subject of the treatment of dropsy, did we not offer a more complete record than we have yet done of the various medicines which have been proposed as specifics in this disease. We may comprehend these under the various heads of purgatives, diuretics, emetics, sudorifics, tonics, frictions, scarification, acupuncturation, paracen- tesis. The operation of some of these we have already discussed, and here, therefore, ue shall do no more than enumerate them. Purgatives. — The principal of these are the croton tiglium, from which the croton oil is ex- pressed, and in which form alone we know the remedy in this country. The dose is a single DROPSY. 717 drop, and this will operate in manv instances most violently, producing within half an hour sickness, vomitmg, and profuse alvine discharges. Dr. Good recommends the alcoholic solution first proposed by Dr. Nimmo, but we have never found the oil do any real mischief. There are individuals upon whom it wi:l not act at all, or who require four or five drops to ensure the operation. With such idiosyncrasies the oil must of course be given in the larger dose. Elaterium is also given with the same intent. We have mentioned under the article Anasarca, the form we prefer,' viz. two grains of elate- rium (or half a grain of elatin) combined with a scruple of the extract of gentian, and divided into four pills, one to be given every hour till free evacuations are procured. The common elder and the dwarf elder (sam- bucus nigra, sambucus ebulus) have formerly enjoyed a high reputation as hydragogues; and the former is particularly recommended by Syden- ham. Every part of these plants is emetic and purgative, but the most potent is the inner bark, which may be taken in powder or infusion. The dose of the former is said by Dr. A. T. Thomson to vary from five grains to half a drachm ; we have, however, no personal experience upon the subject, nor can we say to which species of dropsy it is most applicable. If the remark of Sydenham be correct, that it acts equally upon the kidneys and bowels, we should expect it to be particularly serviceable in effusion connected with disease of the liver, when it is thought advisable to unload the system quickly, as experience seems to prove that ascites (and this is the form which usually accompanies hepatic disorder) usually yields more completely to diuretics than to purgatives. Rhamnus catharticus, or common buckthorn, is another hydragogue highly praised by Syden- ham, but which, like the elder bark, has gone out of fashion. Sydenham employed it in syrup, and states that it removes the effusion without distutb- ing the circulation, or rendering the urine higher coloured, as other purgatives are accustomed to do; but that it has the inconvenience of inducing excessive thirst. The dose of the recent berries is one scruple, that of the dried berries a drachm. The dose of the syrup prepared according to the London Pharmacopoeia is from half an ounce to an ounce, the patient drinking freely at the same time of demulcent fluids. Helleborus niger, or black hellebore, has also been used as a hydragogue; and Avicenna,—no mean authority so far as the mere action of reme- dies is concerned, — observes that he had seen more wonderful effects from it than from any other remedy — "but it will not always equally work wonders." The dose as a hydragogue is from ten grains to a scruple. In the employment of black hellebore much care is necessary that the extract be fresh, for, by keeping, it appears very soon to lose its medicinal qualities. The dose above-men- tioned may be repeated at the end of six or eight hours if no operation shall have ensued ; but in practice the utmost caution is necessary that the peculiar poisonous effects do not follow. In some individuals the smallest dose induces inconceiva- ble anxiety. In the few instances where this has occurred in our own experience, the individuals were known to be incapable of bearing the mildest narcotic medicines, from the intolerable distress which always followed their exhibition. Many other purgatives, as gamboge, jalap, scam- mony, neutral salts, have at various times been in vogue for the cure of dropsy, but it scarcely seems necessary to speak of them here more particularly. They all in great measure act in a similar manner, viz. by producing free watery discharges, and thus stimulating the absorbent function. The super- tartrate of potash is rather a mild aperient than a purgative, and occasionally acts also most power- fully as a diuretic. It is remarked, however, by Dr. Ferriar, that it sometimes " neither increases urine nor stool, yet it cures." Its use in dropsy was, we believe, first particularly pointed out in this country by Dr. Home, and in his reports he has related twenty cases in which it was employed. We collect generally from them that it was most beneficial where there was an inflammatory action present in the system, and where there was no actual organic disease. At the same time it ap- pears in some instances to have been serviceable where the liver was deranged. Its action is chiefly that of an aperient, producing profuse watery eva- cuations, without exciting thirst or feverishness. Dr. Thomson states the dose as a hydragogue to be from four drachms to six drachms, in an elec- tuary. Dr. Mason Good says that in order to ensure its aperient action, it ought never to be given in less than ounce doses; but our experi- ence by no means corresponds with this. We have frequently succeeded by giving only drachm doses three or four times a day : after the second day profuse watery evacuations often follow to such an extent that we are obliged to suspend the medicine. In the intervals the milder tonics may be advantageously employed. (See Cathartics). Diuretics. — Digitalis holds the first place, in modern times, in this class of medicines; but as, in the course of this article, we have already men- tioned the circumstances which render it most appropriate in dropsy, we shall only refer the reader for a more particular account of this drug to the article Dii-retics. The squill is certainly a very powerful diuretic, but its powers are much increased by uniting it with other diuretics, particularly the neuiral salts. In some cases, where the inflammatory action is at all high, its operation is greatly favoured by small doses of blue pill administered in such a manner as slightly to affect the mouth. Dr. Black- all observes, that it is much to be depended upon, when, with an oppression of the chest, the urine is scanty, high-coloured, and without serum. How far this last remark is perfectly correct may be questioned ; but that it is highly serviceable when the urine is high coloured, is perfectly in accord- ance with our own experience. The attention of British practitioners was first called to the diuretic properties of the pyrola um- belluta by Dr. W. Somerville, and they are so well attested, that we cannot but regret that more attention has not been paid to it. It is a native of North America, and belongs to the natural family of Ericeff. The latest account is that of Dr. Bigelow, professor of Materia Medica and Botany in Harvard University, in the United States. " In a number of dropsical cases," says 718 DROPSY. this gentleman, as quoted by Messrs. Churchill and Stephenson, « when first given, it made a dis- tinct and evident impression on the disease, com- municating an increased activity to the absorb- ents, followed by a great augmentation of the ex- cretion from the kidneys. The benefit, however, with me, has been in most instances temporary, and it was found better to omit the medicine for a time, and to resume it afresh, than to continue it until the system had become insensible to its sti- mulus. After suspending it for a week or two, the same distinct operation took place on return- ing to its use, as had been manifested in the first instance. It proved in almost every instance an acceptable medicine to the patient, and was pre- ferred, both for its sensible qualities and its effects on the stomach, to other diuretics and alteratives which had been prescribed." The paper of Dr. Somerville, which is contained in the fifth volume of the Medico-Chirurgical Transactions, is valua- ble from the post-mortem examination of Sir James Craig, to whom the plant had afforded very im- portant benefit. In this instance the liver was studded with innumerable tubercles, the perito- neum throughout was thickened, and the intes- tines were glued together with coagulable lymph.* The lungs on the left side were sound, but com- pressed on the right side by three pints of water. The pericardium contained six ounces of water, and the heart was somewhat larger than usual. The history of this case abundantly proves that the original malady was in the liver. According to Dr. Somerville, the virtues of this plant do not reside in any volatile principle, and he found con- sequently that a decoction acted much more ener- getically than an infusion. In order to make this decoction, an ounce of the dried plant, including the root, stalks, and leaves, is cut into small pieces, and macerated twelve hours in two pints of cold water, and then boiled till it yields one pint of strained liquor. Mr. Carter found that thirty-four pounds avoirdupois of the recent herb produced four pounds of extract, which had the same pro- perties with the decoction. Five scruples of this extract in pills or in solution may be given in twenty-four hours. The spartium scoparium or common broom, the leontodon taraxacum or dandelion, the apium pelroselinum or common parsley, the juniperus communis, and the colchicum uutumnale, all possess considerable diuretic powers, and may fre- quently be united with some of those above men- tioned, with much advantage. The meadow-saf- fron is perhaps the most powerful of all these, and we have succeeded with it in conjunction with mercurials, in acting upon the kidneys in hepatic disease when no other remedy had any effect. The spiritus colchici ammoniatus of the London Pharmacopoeia is the preparation which we have chiefly relied upon, given in half-drachm doses three times a day, with a blue pill night and morning, and sometimes mercurial frictions over the abdomen being added. In the 57th number of the Journal Hebdoma- daire, for October, 1831, M. Le.nasson has given a detailed account of the employment of the bark * As. however, he hail h-m, frri|.,,.ntlv tapped, this last appearance was probably a consequence of ine opera- tion, and not a part of the original disease. of the root of the chiococca racemosa auguifuga, or snow-berry tree, belonging to the natural family of the Rubiaceaj. This bark furnishes a bitter prin- ciple, crystallizable in delicate needles, without smell, of a bitter and rather an astringent taste, soluble in water, very soluble in alcohol, espe- cially when warm, and reddening the tincture of turnsole; in this principle all the peculiar medical properties reside. This remedy is said by M. Le- masson to be chiefly applicable to atonic dropsies. A decoction of the bark is made by macerating two drachms of the bark in eight ounces of water, then boiling for ten minutes, and straining the liquor off, which is divided into two doses, and the second dose is taken two hours after the first. The cases related by M. Lemasson are all con- nected with great general debility of the system. One was a case of chronic bronchitis with slight dilatation of the heart, and in this patient the fee- bleness was very considerable. Two were the consequence of syphilis and mercurial courses, to which universal anasarca succeeded, but without any particular visceral disease. In one patient affected with dilatation of the right cavities of the heart, the exhibition of the bark was preceded by bleeding. The effect in all was an improvement of the appetite, and a great increase in the flow of urine. The medicine is administered as above- mentioned in two four-ounce doses, with an inter- val of two hours between the first and second dose ; when this affects the kidneys, they continue their action for several days, and the medicine is not again exhibited till the urine diminishes. In the first case which was related, it was given on the 18th of June, on the 20th of the same month, and not again till the 5th of July, after which it was not repeated. In the second case it was only given twice. On the 22d of May, and on the 29th, both terminated successfully, and the medi- cine had a similar effect of increasing the appetite and the flow of urine together. Emetics.—These have been recommended by some authors, and cases have been given, in which they have succeeded when other remedies had failed. We have ourselves no experience of their effect in this disease, and they appear to be ban- ished from modern practice. We shall content ourselves therefore with this intimation. Sudorifics.—These are unquestionably in some cases highly useful, more particularly however when disease of the lungs is present. The vapour- bath has occasionally been successful in such cases. The celebrated Dampier cured himself by covering himself all over with sand, heated by the sun, in California, for an hour, after which " he was carried to his bed and well covered with clothes, where he fell into a profuse sweat, after which he recovered daily." The compound ipe- cacuanha powder has in this way been successful, and we have seen ascites attended with liver dis- ease removed by it, though the patient died soon after, from the original malady. Tonics.—Every species of dropsy may in some part of its course require the exhibition of tonics, for a state of debility easily follows depletion, however necessary it may have been ; and it has not unfrequently happened that a patient has been cured of dropsy, and died of the weakness induced by the remedies. To obviate this, appears to DROPSY. 710 1? W ^^"f^ ce,ebrat?d plectua" is a combination of scammony, Biilnh.,,„. c ■ ----","","uu'i «« seammony, sulphuret of iron, and crude mercury. Of this formula D, Blackall says, that "it has certainly pe formed many cures, and there is so much de- bility in the disease, that the addition of tonics to purgatives, never indifferent, is particularly desi- rable here, where it can be made with safety." Steel and bark are the principal tonic remedies hat have been used in dropsy, and we consider the ferrura tartanzatum to be the best preparation of the former, as it unites a diuretic with its tonic properties We have usually given it in combi- nation with infusum calumbse, and particularly in those asthenic dropsies in which the heart or lungs are diseased. In the asthenic dropsy con- sequent to chronic bronchitis, united with coun- ter-irritation of the chest, it will sometimes alone remove the effusion. The sulphate of quinine is given with the same intention, and in weak and scrofulous habits it seems preferable to the prepa- rations of steel. Dr. Blackall prefers bark also in the debility consequent to dropsy after an acute disease. In the exhibition of these tonics the ut- most care is necessary that they are not given in an inflammatory state of the system, nor while the tendency to inflammation remains ; but when by bleeding, digitalis, and other evacuants, the effu- sion has nearly disappeared, and the urine reco- vered its natural state and quantity, tonics will complete the cure, and secure the patient from a relapse. The action of the remedies just mentioned is more distinctly known than that of the tonic pills of Bacher, and which we have noticed under the article Ascites. More like cream of tartar than common tonics, these pills seem sometimes to be merely anti-hydropic, removing the effusion with- out inducing any increase in the urine or alvine evacuations. The dropsies in which we have found them most useful are those which occur in girls about the age of puberty, without manifest derangement of any particular organ, and we have observed them to be more useful in ascites than anasarca. The younger Bacher, in speaking of black hellebore, says that it is not applicable to cases in which the solids are firm, nor when the fibre is greatly relaxed and weakened, but when, with some degree of debility, the circulation is irregular, and determined to some particular organ. We may observe, however, that in many of the cases he has related, no such determination is in- dicated by the symptoms enumerated, and in our own practice they have seldom been of use, when there has been evidence of organic disease. The action of these pills, as we have already mention- ed, is often imperceptible, but at other times they procure copious evacuations from the. kidneys and bowels, and sometimes, according to Bacher, they cause profuse perspiration. The following is the formula of Bacher, as published by his son :— R Extracti hellebori nigri, Myrrhs solutffi, aa, §i. Cardui benedict, pulv. gui^i. M.s. n. Fiat massa aere sicco exsiccanda, donee forman- dis pilulis apta sit. Singulae ad grana sex. Ten of these pills were given three times a day. We have repeatedly cautioned medical practi- tioners against the danger which may ensue from the poisonous properties of the black hellebore, and here therefore we shall only inculcate ex- treme watchfulness whenever this remedy is ex- hibited. It is probable that many other of the common j mineral and vegetable tonics may be employed in I asthenic dropsy, and it will always be advisable j that the practitioner should, as far as possible, be j provided with substitutes, as, from particular idio- syncrasies, individuals are sometimes incapable of taking what may in other respects be the most i appropriate remedy. [Methodical compression, where it can be em- ployed, is often of decided service in promoting ■ absorption ; at other times, it is employed only as a support when the integuments are largely dis- tended with the fluid of dropsy. Frequently, the benefits from compression are more apparent than real—the fluid being simply forced from the cel- lular membrane pressed upon by the bandage, and returning to its former position when the pressure is withdrawn.] Friction___Under the head of Ascites, we have referred to a case in the 49th volume of the Philosophical Transactions, in which friction with oil effected a cure in an old case of ascites. We are unacquainted with the particular symptoms which more particularly indicate this remedy, but there certainly can be no objection to it in any 1 case in which the abdomen is free from tender- ness. j Blisters.—These sometimes afford great relief, I and we have often had recourse to them in our ' own practice. They are not, however, always ; unattended with danger, and whenever they are I applied, the surgeon ought to be requested to at- tend to their progress. We have more than once [ seen death hastened by the blistered surface be- | coming inflamed, and mortification ensuing. Scurifications.—These are indeed the opprobria medicina?. They afford relief from the pressure | and weight of the effused fluid, but too often at ! the same time give rise to inflammation, gangrene, ! and death. Yet there may be cases in which the distension is so great and the distress so intense, that the operation may not only be justified, but may be demanded. Upon this head we would briefly remark, that in old and very debilitated persons they should seldom, perhaps we might more properly say, they should never be practised, and that in young persons in whom the repara- tive process is more readily set up, great attention should be paid to their appearance and progress. The mere presence of dropsy will make no differ- ence as to the proper manner of treating the wounds ; but if inflammation be present, or gan- ; grene, the same local and general remedies must be recurred to, as if no effusion had existed ; nor indeed is this only useful to the wounds; fre- quently when the fluid has escaped, the tonic and stimulating remedies which the surgical treat- ment has required, have prevented the return of the effusion. Acupuncture.—This is only a milder manner than scarification, of effecting the mechanical escape of the fluid; and the remarks made upon the former are equally applicable to the present remedy. Evil consequences are perhaps less frc- 720 DYSENTERY. quent, but still they do not unfrequently occur. (See Acupuncture.) Paracentesis.—Of this operation we have spoken under the head of Ascites, nor does it appear to us necessary to add to the remarks which we. have there made. Diet___The only point that remains to be no- ticed is that of diet, but upon this head, we do not feel called upon to make many remarks, nor should we indeed have mentioned it at all, had it not been for the vulgar opinion which formerly prevailed, that fluids ought not to be allowed to dropsical patients. Even this notice is perhaps quite unnecessary, as the error is, so far as we know, completely exploded. Sir Francis Milman first examined the question, and gave the most satisfactory evidence that the restriction from fluids was not only not beneficial, but was in many cases even injurious; and since his time, so much additional evidence has been obtained to the same purpose, that to allow dropsical patients as much fluid as they wish to drink, is becoming an axiom in the treatment of disease. It has been well ascertained that many diuretics only stimulate the kidneys in proportion to the quantity of liquid in which they are given. With respect to the nicer question of food, it seems unnecessary to make any remark: this must be varied with the nature of the dropsy, and the symptoms by which it is attended; and who- ever understands the meaning of a phlogistic and antiphlogistic regimen will know how to apply either of these, or to vary from one to the other, in the disease of which we have been treating, as circumstances may require. John Darwall. DYSENTERY.—This word is derived from the Greek word Svocvrepia, which is compounded of Sic (difficile, xgre, mule,) and ivrepov (intesti- num), and signifies that the intestines are mor- bidly affected. By Celsus the disease is named tormina, from one of its leading symptoms; and by Caslius Aurelianus rheumatismus intcstinorum cum ulcere. Dr. Ballingall applies to it the not inappropriate appellation of colonitis. By certain French writers it is called colitis (colite), and in common language it is named flux or bloody flux, according as the intestinal discharges are free from blood or sanguinolent. It is placed as a genus in the class pyrexix, and order prnfluvia of Dr. Cullen ; in the class fluxus, and order alvifluxus, of Sauvages; and, very correctly, in the class hx- matica, and order phlogotica, of Dr. Mason Good. Division of the Disease. — Dysentery con- sists, in its early and acute stage, of inflammation of the mucous membrane of the intestines, espe- cially of the colon and rectum. This inflamma- tion, by implicating the other coats of the bowel, and by generatin be pursued becomes sufficiently obvious. Bloodletting naturally presents itself as one means of subduing the inflammation ; and if the constitution sympathises with the local affection, so that there is general fever, with a warm skin and a frequent and sharp pulse, blood should be taken freely from the arm. We should not rely upon general bleeding as the sole mode of deple- tion in the disease, for experience teaches us that the inflammation of mucous membranes is less amenable to this remedy than that of most tissues; but it should be followed by local bleeding by means of leeches; and in the milder order of cases this may altogether supersede general deple- tion. Twenty or thirty leeches should be applied along the course of the colon, or to any point of the abdomen where pain is felt, the parts being subsequently covered with a hot poultice. The repetition of leeches must of course depend upon the intensity and duration of the disease, and the degree of relief afforded by the first application. Should griping, purging, and particularly fixed abdominal pain continue, they may be repeated on the following day, or each succeeding day, to the third or fourth time, if the circumstances men- tioned indicate the propriety of the repetition ; their number in the later applications being regu- lated by the necessity of the case and the strength of the patient. It should be remarked, however, that the first application, if vigorous, frequently affords so much relief, that, by the aid of internal medicine, the disorder proceeds thenceforward very steadily to recovery. Hot fomentations and the warm bath will be found serviceable after the bleeding, and subsequently the abdomen may be blistered with benefit. Purgatives are generally administered; and, during a considerable period when the retention of feculent matter in the cells of the colon was erroneously supposed to constitute the very essence of the disease, they were principally depended upon by some practitioners for its cure; and though the more correct views at present enter- tained may seem to forbid their employment, experience teaches us that to unload the bowels, when requisite, with gentle laxatives, is not only safe but beneficial. Were the writer to digress into a question of general therapeutics, but one connected with the present subject, he would remark that though laxatives are found prejudicial in neuralgic irritation of the intestinal canal, he has never observed injurious effects from their moderate and judicious employment in inflamma- tion of its mucous lining; and that he has detected the most extensive lesions of this mem- brane, where the practitioner had rigidly abstained from them. It is desirable, however, that the abuses which heretofore existed, regarding their employment in dysentery, should not be resusci- tated, and on this account it appears advisable to specify the sole circumstances under which they should be administered in this disease, and the precautions this administration requires. In every case of dysentery, the first remedial measure should be directed to subduing the essen- 726 DYSENTERY. tial disease, the intestinal inflammation ; the pri- mary and paramount means, therefore, are the general or local bleeding, or both, as the circum- stances of the case may require. In that form of the disease which is un preceded by diarrhcea, a dose of castor-oil, sufficient to expel the matters lodged in the intestines, may be given after a little respite from suffering has been obtained by bleed- ing ; and should its operation be tardy, it may be accelerated by a mild emollient enema. In that more frequent form of the disease which has diar- rhoea as a precursory symptom, purgatives should by no means be employed early ; but in any form of dysentery, should a considerable period have elapsed without a feculent discharge, a mild laxa- tive will be advisable, for the retained matters are generally in a morbid condition, and can scarcely fail to be a greater source of irritation to the in- flamed membrane than the operation of a gentle laxative. The repetition of medicine of this kind will of course depend on the circumstances of the case ; should the alvine discharges become fecu- lent and copious, it need not be repeated. No more proper laxative can be selected than the oleum ricini, aided in its operation by a mild, tepid, and emollient enema. Some practitioners think favourably of a solution of neutral salts with which a proportion of tartarized antimony is combined ; but it seems doubtful whether the irri- tating effect of the salt on the intestines would not counterbalance the benefit likely to accrue from the diaphoretic action of the antimony. Mercury is so powerful a subsidiary of general and local bleeding in the cure of inflammation, that we should naturally expect benefit from it in this disease ; and experience proves its prudent employment to be of great service. It might be objected to on the same ground as purgatives, the dread of an irritating effect from it on the in- flamed intestine; but the result of its employment, our only safe guide, shows the apprehension to be erroneous, provided the medicine be properly administered. It is a remedy more generally ap- plicable to dysentery in warm latitudes than in this country ; but if employed with prudence, and merely as subsidiary to the general or local bleed- ing, or both, advantage will be derived from it wheresoever the disease may be prevailing. A grain or a grain and a half of calomel, combined with from five to ten grains of Dover's powder, or half a grain of opium ; or five grains of hydrar- gyrus cum creta, likewise combined with the opiate; may in this country be administered at intervals of four hours, the period being length- ened when the symptoms begin to abate. It is not necessary to excite ptyalism, although this is a contingency from which no evil result need be apprehended, provided the medical attendant be sufficiently watchful of the effect of the remedy to prevent its being excessive. In warmer climates, the same dose of mercury, combined with a smaller proportion of Dover's powder, or a grain of ipe- cacuanha, may be given every hour or two till some effect is produced on the disease or the sys- tem. In our Indian settlements the practice is much bolder than this, calomel being administered in doses of a scruple. Mr. Annesley gives such a dose nightly, followed by an oily or a saline pur- gative in the morning, till the dejections become natural and healthy, (Sketches of the Diseases of India, p. 417 ;) and calomel in such doses is a familiar remedy with British physicians in tropical climates. Diaphoretic medicines are employed by many medical men in dysentery. The cerated glass of antimony, which was a favourite remedy with Sir John Pringle and others, probably owed great part of its influence over the disease to its power of exciting perspiration; and the combination which has already been mentioned, that of a mer- curial preparation with Dover's powder, perhaps derives part of its very great utility from the same property. Ipecacuanha alone is a valuable medi- cine of this class. It may be given in large doses in the form of pills without exciting vomiting, as in the manner recommended by Mr. Twining in the Calcutta Transactions. By combining it with extract of gentian he exhibits as much as six grains, which he repeats at intervals; and, as he assures us, with an excellent effect. A decoction of three drachms of the root, boiled in a quart of water down to a pint, administered in portions of three or four ounces, as an enema, and repeated once or twice in the day, we have often found to have the effect of allaying irritation and tenesmus, and to be generally beneficial. The same medi- cine is frequently combined with calomel, or other mercurial preparations, with considerable improve- ment of the efficacy of both. Emetics are favour- ites with some practitioners, but the benefit to be derived from them is much more certainly and easily attained by nauseating or diaphoretic doses of ipecacuanha. Tenesmus is frequently a distressing symptom. Of course effectual relief can be afforded only by the general process for subduing the disease; but it may be allayed by anodyne enemata, of which a solution of three or four grains of opium in a small quantity, not more than two ounces, of starch mucilage, constitutes a very good one. Dr. Abercrombie recommends injections of lime- water, at first diluted with milk or thin arrow- root, with the addition of an opiate. It should be impressed on the minds of junior practitioners that enemata administered with the view of allay- ing tenesmus should be small, for this affection is aggravated by distending the lower portion of the intestinal canal with bulky fluids. Mild emollient clysters have already been recommended as adju- vants to the oleum ricini when there is retention of feculent matter in the intestines ; but it should be understood that their employment in these cases is admissible only when the irritation of the inferior portion of the canal is not extreme. We have met with instances in which even the intro- duction of the pipe could not be borne. In such cases as these, tenesmus and irritation may be allayed by opium, Dover's powder, a dose of lau- danum, or by opiates combined with infusion of cusparia or balsam of copaiba, administered by the mouth. Dr. Cheyne, whose practice in the dysentery of this country has been very extensive, thinks highly of the power of opium in its cure, and gives the following summary of his experience of its efficacy and that of other remedies. The mode of treatment he found mo.st generally useful was bloodletting, followed by calomel and opium, and DYSENTERY. 727 this by balsam of copaiba and farinaceous diet; and he says, « were the same cases again to be placed under my care, I would not hesitate to give opium in doses of four or five grains, as it was the opium chiefly that seemed to arrest the progress of the inflammation; and whatever in such a case procured respite to the patient from agony, sometimes proved of permanent benefit." (Dublin Hospital Reports, vol. iii.) This testi- mony, proceeding from such a quarter, should have great weight. The concluding clause con- tains a truth of much importance, and one appli- cable to many diseases besides dysentery. [Dr. Christison expresses the belief, that the cure of epidemic dysentery may often be effected by opium alone, begun early and given boldly. In one epidemic, it was prescribed at once in the dose of one, two, or three grains every six, four, or three hours, according to the urgency of the symptoms, until signs of its narcotic action began to display themselves; and in this way sometimes twenty and even thirty grains were given in the first twenty-four hours. In several cases, where the treatment was commenced not later than the close of the second day, the force of the disease was at once completely broken, and the only reme- dies needed afterwards were the continuance of the opium in diminished doses, and restricting the patient to pulpy solids as diet. The writer has often seen the excellent effects of opium in this as well as in other inflammations, given in seda- tive doses ; but caution has to be used that it be not pushed too far.] Swathing the abdomen with flannel, so applied as not to press painfully, is useful as a means of keeping the temperature uniform. Should abdo- minal pain require relief, hot fomentations may be frequently and freely resorted to. If the anus be inflamed or excoriated, it should be bathed with goulard water ; and it may be protected from the acrimony of the discharges by being anointed with unguentum cetacei, or wax and oil. The diet throughout the disease should be mild and light, consisting of arrow-root, milk, simply, or with gum acacia dissolved in it, rice or barley- water, and mucilaginous and bland matters of this description; they should be given in small quan- tities at a time, and the whole amount of what is taken should be small. Treatment of Chronic Dysentery. — Our indications here are much more perplexed, and our difficulties much greater, than in the acute form of the disease. That intestinal ulcers occa- sionally heal has been proved by Dr. Troilet, (Journal General de Medecine); and Dr. La- tham, in his account of the disease which prevailed in the Penitentiary at Milbank, has given an ex- cellent description of intestinal ulcers in the pro- gress of reparation : hence we should not utterly despair of success in this very intractable malady. As in most diseases which are but little amenable to our art. the remedies proposed are very various. Those which deserve the most confidence are small doses of hydrargyrum cum creta1 or calomel with Dover's powder, or the same mercurial prepara- tions with opium and ipecacuan; lime-water; vegetable astringents and bitters, as kino, catechu, cusparia. quassia and logwood; nitric acid ; opi. um; balsam of copaiba or tolu; or various combi- nations of these remedies, as a strong decoction of cusparia with nitric acid and laudanum, recom- mended by Dr. Abercrombie. The late Dr. Jack- son, whose experience of this form of disease was very extensive, placed much reliance on small general bleedings, repeated at intervals of a week ; but in a disease attended with so much debility as this, very moderate local bleeding from the integu- ments of the abdomen, and the application of blis- ters to the same parts, appear to be safer methods of accomplishing the object to be attained. Mo- derately stimulating and oleaginous frictions of the abdomen, the part being subsequently swathed with- flannel, are occasionally found useful; and the warm salt-water bath is soothing to the pa- tient, and generally beneficial to the disease. Pow- dered charcoal, combined with powder of ipeca- cuan and rhubarb, has been found advantageous; and Dr. Abercrombie speaks favourably of a com- bination of the same substance with Dover's pow- der. The writer has found considerable temporary benefit in this distressing affection from the sul- phate of copper, administered in the manner re- commended by Dr. Granville in various chronic affections of the bowels. It is given in doses of half a grain with an equal quantity of opium ; and is gradually increased, if necessary, sometimes to the extent of three grains, with half-a-grain or a grain of opium three times a day. Where there is reason to suppose that the lower part of the intestinal canal is the seat of ulceration, various injections are employed with advantage. A weak solution of acetate of lead or white vitriol has the effect of allaying irritation ; whilst a solution of blue vitriol, or one of corrosive sublimate in lime- water, excites foul and sluggish ulcers to healthy action, and in some cases has appeared to aid materially in effecting a permanent cure. These injections should not consist of more than two or three ounces of fluid, for great irritation is pro- duced under the circumstances mentioned by dis- tending the canal by large enemata. [The various remedies recommended in diar- rhoea (q. v.) are equally appropriate in the affec- tion under consideration.] The diet, throughout the disease, should con- sist of the mildest and most bland farinaceous food, taken in small quantity, solid animal food and all stimulating matters being rigidly forbidden. Solid food, in any considerable quantity, must be injurious as a more mechanical irritant in that condition of the intestines which beyond a doubt exists in chronic dysentery ; whilst liquid freely taken excites griping, passes rapidly through the bowels, and must tend to disturb that reparatory process which it should be our object to encourage. If the disease have commenced in a district where dysentery is endemic, change of air is a remedy of first importance, and one without which all other means will often prove nugatory. A sea voyage has frequently proved very advantageous. The treatment to be adopted in dysentery, complicated with idiopathic fevers, will be ga- thered from the rules contained in this article, and in the articles on continued and periodic fever. The combination with liver disease, the hepatic flux of Ballingall, and others, requires mercurial treat- ment by means of blue-pill, calomel and opium, or inunction, till ptyalism is induced ; and this, 728 DYSMENUKKfiCEA. unless the exhaustion of the patient forbid it, is to be kept up till the discharges assume a healthy appearance. Laxatives are occasionally requisite, and of these castor-oil is the most proper. The warm-bath, sudorifics, blisters, and bandaging the abdomen with flannel, are as important as in the treatment of the uncomplicated disease; and should the tenesmus be distressing, it may be al- loyed by any of the forms of anodyne enemata recommended in that disorder. Joseph Brown. DYSMENORRHEA, (from Si>s, xgre,- pnm, menses; pta, fluo,-) painful or difficult men- rtruation.—This disease is important from its occasional extreme obstinacy ; from the great suf- fering which it produces, and from the contrariety of opinion which prevails as to its nature, and the treatment required for its relief. In healthy men- struation there is often no warning whatever of the period; more generally there is some degree of discomfort, consisting of a sensation of weight and fulness about the pelvis, with a bearing down and aching of the thighs, but usually the suffering is so slight as not to call for medical aid; in dys- menorrhea, however, the menstrual period is ac- companied with such acute pain and suffering, and is looked forward to with such apprehension, that the patient is eagerly inclined to seek for re- lief, and is but too often driven from one remedy to another with but trifling advantage. The time at which the pain comes on varies in different cases. In many the pain precedes the discharge, or else the discharge is exceedingly scanty as long as the pain lasts ; but as the quan- tity increases to a full flow, a subsidence of the suffering takes place ; in these cases the pain will last only a few hours. In other instances the discharge is more profuse than natural during the whole continuance of the pain, is apparently ex- pelled in gushes, and is then usually mixed with coagulated blood. In a few more rare cases the pain will only occur in the latter part of the men- strual period, accompanied either with a diminu- tion or an increase of the flow, and ceasing only after every vestige of the discharge has passed off. All these varieties will be found in practice, though in the histories of this disease some have been often omitted, and most authors have de- scribed the pain as occurring only at the onset, and ceasing when the full and free evacuation takes place. The [iain often resembles the grinding pains of the first stage of labour, and is similarly in pa- roxysms of short duration and frequent recur- rence. There is also, in the intervals, a constant aching pain down the legs, with a dragging sen- sation in the back and loins ; there is sometimes, also, a sensation of bearing down in the pelvis, with even an actual lowering of the uterus. All these pains will vary in degree ; for in some severe cases the paroxysms have been so violent that the patient has rolled on the bed or the floor with agony, and, in a few instances, the writer of this article has noticed severe convulsions of the cha- racter of tetanus, even amounting to regular opis- thotonos. The expulsion of a membranous sub- stance has been observed in dysmenorrhea by Morgagni, (Epist. 48, art. 12,) who described it as generally consisting of a small bag, containing a fluid, on which account it was usually mistaken at that time for a very early abortion. M(p itat. Medic, t. iv. {A female alter ahor- lion.) Ruysch, Adversar. Anat. D"0. n n. II. (A female after parturition.) Wil.is, Ue Urnii*, ea,.. v. (A female Buffering under calculus.; 1'ahncr, ile, Irii^e zur uracils Chen und gericlitliclien arzney kunde, b. i. n. v. Guisard. Pratique du Cfiirurgie. tunics. The sudden occurrence of pain in the re- gion of the bladder, and incapacity to expel the urine after the reception of an injury, the absence of tumour of the bladder when examined through the rectum or vagina, and the scanty discharge of jets of bloody urine by the catheter, will in gene- ral point out the real nature of the accident It is to be observed in relation to the diagnosis, that although the bladder have been ruptured, there is often circumscribed tumour in the hypogastric re- gion. In an instance of ruptured bladder which occurred in our practice some years ago, a urinary abscess which pointed in the hypogastrium was punctured on the twelfth day after the accident, and the patient survived till the twentieth. On inspection, the small intestines were found glued together, and to the abdominal peritoneum, by an albumineus exudation ; and thus a partition was formed between the upper and lower portions of the abdominal cavity, which stretched across in an arched form a little below the navel. The lower cavity, which was of great extent, and communi- cated under the left Poupart's ligament with a sinus passing for several inches down the thigh, was more than half filled with putrid urine, pus, flakes of albumen, and liquid fasces; for the intes- tines had given way in several places. The blad- der was seen lying collapsed in its natural situa- tion, and presented posteriorly, on the left side of its upper fundus, a rounded opening about two inches in diameter. The peritoneal coat was ex- tensively separated at this point, and its edges hung loose in flocculent shreds. It is probable that in this case only the mucous and muscular tunics were at first ruptured, and its long duration afforded some slender hope of a favourable termi- nation : the only chance of success was from an early puncture of the hypogastric tumour, which we proposed in the second day after the accident, but it was overruled in consultation. Dysury often originates in a want of power in the muscles which expel the urine. The muscu- lar fibres of the bladder, if long kept on the stretch, gradually lose more and more of their contractile force, and at length become wholly paralysed. In- stances of this description are of daily occurrence, when individuals have been prevented from empty- ing the bladWr by delicacy, or by the absorbing engagements of business or pleasure. The pres- sure of the child's head in the latter stages of parturition often keeps the urine pent up, and thus induces inability to expel it after the obstacle is removed. The same loss of power in the fibres of the bladder, though in a much more dangerous form, arises from affections of the brain and spinal cord, and from pressure and disorganization of the nerves which supply the bladder : in this way difficulty of voiding the urine occurs in fevers, in extravasations and effusions within the cranium, in pressure from fractures of the bones, and in in- juries and chronic diseases of the spinal cord. Among the causes of dysuria, there is none more familiar to common observation than the ex- posure of the body to cold. It acte by producing a contraction of the urethra, more especially in men, disturbs and destroys the natural consent of parts, and in the end induces a torpor of the blad- der. Wherever a predisposition to dysury exists from mechanical obstruction or otherwise the DYSURIA. 737 action of cold becomes an immediate exciting cause. e Treatment---In attempting the treatment of cases of difficulty or inability of voiding the urine, our first object ought to be to ascertain the cause from which it proceeds, and, if possible, to re- move that which has occasioned the symptom : if we succeed in accomplishing this, the dysury in a great, majority of cases will cease. In every in- stance of this affection it is of especial importance to discover how far it is connected with an in- flammatory or plethoric condition of the body, or of the urinary orSans in particular; and should it give great relief in the painful micturition which attends gonorrhoea. When difficulty of voiding the urine occurs, as it very often does, after partu- rition, the simple expedient of making pressure on the hypogastrium with a warm sponge will not unfrequently save the patient from the necessity of having the urine drawn off by the catheter. But to this instrument we must have recourse in very many cases of retention of urine; and it is fortunate that the surgeon possesses in it the means of removing a symptom which is at once most distressing and dangerous. The catheter, however, is not always successfully employed, be so, to have speedy recourse to bloodletting and even by surgeons of acknowledged eminence and leeches. When dysury occurs during pregnancy, or is symptomatic of approaching abortion, the adoption of this practice will generally be required. When the affection is of a spasmodic character, or accompanied by pain or irritation, the warm- bath, warm applications of various kinds, and opiates by the mouth, friction, or enema, will be found of the greatest utility. The last of these remedies is particularly serviceable in that form of dysury which is caused by the application of can- tharides. In many cases of dysury, even where it depends on a certain degree of mechanical ob- dexterity; and it then becomes a question how the danger can best be averted. If the symptoms are not urgent, a little delay may still be allowed, to give a farther trial to the most important of the remedies already enumerated, and to the well- directed employment of sounds and catgut bou- gies ; but we must on no account wait so long as to incur the slightest risk of gangrene or rupture of the bladder. The only means now remaining by which the life of the patient can be saved, is, to puncture the bladder, or open the urethra behind the obstruction, should such be the nature struction, the operation of a smart purgative has , of the case. This, however, is in the province of produced immediate relief; and in every instance it is a safe rule to unload the bowels as speedily as possible, for by this means we relieve the neck of the bladder from pressure, and promote the healthy sympathy of the parts. In dysury and retention of urine of a spasmodic character, the tincture of the muriate of iron, in small repeated doses, has proved a valuable remedy in the hands of the late Mr. Cline and many others. The sud- den effusion of cold water on the genitals and neighbouring parts has sometimes procured a flow | of urine when all other methods have failed, partly, ! perhaps, by causing a relaxation of spasm, but chiefly by rousing the contractile powers of the bladder. But when the vigour of this organ is actually impaired, we must have recourse to sti- muli of far more effective and permanent opera- tion. Blisters to the loins and sacrum, the forma- j tion of eschars by moxa or potassa, and the cau- tious exhibition of cantharides, areftthe remedies which will be found of most avail. J When dysuria appears to be connected with the scanty secretion or acrimonious quality of the urine, diluents are to be given freely, along with such mild diuretics as the spiritus stheris nitrici, spirit of juniper, decoction of the fibrous roots of the leek, liquor potassa? with hyoscyamus, bicar- bonate of soda, or Seltzer water. Stronger diuretics are in severe cases given with advantage, such as the parsley breakstone (alchemilla arvensis), seeds of the wild carrot (daucus sylvestris), and the oil of turpentine. Dysury from alkaline urine must be treated on the plan already laid down in the article Calculus. Should inability to void the urine have arisen from long voluntary retention of it, the patient ought to immerse his feet in warm water, and, placing the penis in a basin of the same, make gentle pressure on the hypogastrium, and endea- vour to evacuate the bladder, when he will often succeed without any farther assistance. The im- mersion of the penis in warm water rarely fails to Vol. I. —93 3m» the surgeon, and therefore foreign to the nature of our work' W. Cumin. [EAR, DISEASES OF THE. (See Otalgia and Otitis.)] ECTHYMA, (from Ik, ex, and Svciv. fervere,) a disease of the skin, characterised by an eruption of phlyzacious pustules, neither contagious nor I infectious. Synonymes.—TfppuvOoc vel OipptvBos,* et imvvK- I "«■,-(- (Grxcorum ;) iherebinthus, (Latinorum;) albotin vel albotes,^ schera et botsor,§ (Arabo- rurn,-) termiiithus, (Wiseman, Turner, Lorry, Plenck ;) epincytis, (Sauvages,-) psoride crusta- cee, (Alibert,-) Erbsenblattern, (Teutonice sec. j Plenck;) eiternde Flechte, (sec. Sprengel;) pa- • pu/ous scall; ulcerated fetter. By the term with wliich Willan chose to desig * " Some will have the denomination from the likeness of the pustule to the fruit of the terebinthus. Others, with more reason, read it ipitiivOos; eiccr, which it somewhat resembles." Turner. Vide Hipp. Epidem. lib. ii. sect. 11; De Humor, xi. 1; Galen, in Exeg. diet. Hipp, item Comment. 3, De Humor, et Comment. 4. in lib. vi. Kpidein.; ./Egin. I. iv. c 4; JFAii. lib. ii. ta;- trab. iv. c. 6.J; Foes. (Ec. p. 615, 1516; M. Aurel. Sev. I. de Epinyctid. part. ii. contr. 3; Dioscorides Alexand. vide Gorr.-ei defin. Med.; Oribas. lib. vii. Syncop. exxxvi. t From im and viii;, so called, according to some, because the eruption first appeared, or only appeared, by night, and, according to others, because it was most trouble- some at night. But whatever be the reason of the ety- mology, it is plain, from the description of this eruption left us by the best authorities, thai ll consisted of phly- zacious pustules. Vide Hipp. Prorrhet 2, De Intern. Affect.; Celsus, lib. v. c.28, sect. 15; Paul. iEgin. lib. iv. cap. 9; Oribas. Synops. lib. vii. c. 37. The Arabians translated the term by sera or schera, and sometimes botsor, (Avicenn. lib. iv. fen. vii. torn. iii. c. I.) which last being of the same etymology, restored it to its natural connection with tcrmmthus. Actuarius, as it appears lo us with little show of reason, insists on a distinction between epirtyctis and termmthus, (Meth. Med. lib ii. r. 11, 12.)- Some authors, bearing entirely upon the deri- vation of epinyctis, have been led into the mistake of considering it the same as the urticaria tuberosa — an error which Sennertus very properly corrects. \ Fallop. 1. de Morb. Gall. c. 5, torn. i. p. 086. § Avicenn. lib. iv. fen. 3. t. i. and f. 7, t. iii. c. 1; Hen- sler de Herpete, p. 30; Roussel de Herpete, § 99. 738 ECTHYMA. nate this disease he lost hold of the thread which led us to the knowledge which the ancients had concerning it. In the synonymy we have endea- voured to recover it, thus to connect ancient expe- rience with modern observation, the only substan- tial use of learning. The eruption in this disease consists of large round pustules generally distinct and sparingly scattered, each having a hard, red, elevated base, terminating in a thick, hard, greenish or dark- coloured scab, which, falling off, leaves generally a livid red spot of longer or shorter duration, some- times a superficial cicatrix, more rarely an ulcer, seldom a tubercle. This eruption is frequently confined to the ex- tremities, appearing most commonly on the legs, on the outer side of the thighs, arms, and forearm, frequently on the abdomen, nates, lumbar region, neck, and front part of the chest, rarely on the face or scalp, and very seldom occupies the whole body. The pustules sometimes break out together in successive crops ; but generally they appear, go through their progress, and terminate, indepen- dently of each other, some being on the decline whilst others are appearing. This eruption is sometimes, but not generally, accompanied with fever; it is more frequently attended with restlessness, a state of general irri- tation or erethism, and sleepless nights. Morbid phenomena produced by gastric and intestinal irritation, as anorexia, &c, almost always appear during the course of the eruption. Sometimes fever, anxiety, great general distress, and pains of the limbs precede the eruption, which subside on its appearance. If the pustules be abundant, thickly set, violently inflamed, and acquire a great size, considerable symptomatic febrile action may be present; and if they ulcerate, are slow in their progress, and of long continuance, emaciation, debility, and regular paroxysms of hectic fever supervene. Each pustule generally commences in a circum- scribed red inflamed point, which becomes gra- dually raised, and in the course of a few days acquires a size varying from that of a lentil to that of a sixpence; their apex is soon observed to point with pus, whilst the base continues hard, circum- scribed, and of a bright red colour ; at the end of three or four days the pus dries, and scabs, more or less thick, are formed, which, when they fall, leave spots of a dark red colour. The pustules vary in size, from that of a small pea to that of a sixpence or larger. They are generally distinct, I but sometimes they form irregular clusters. Their I development is frequently accompanied with very I acute stinging pains, similar to what precedes I erysipelas, or the herpes zoster. From this their usual course considerable de- viation is sometimes observed. Their progress is sometimes tediously slow and imperfect. Suppu- ' ration in some cases is established rapidly, and in '• others it is only effectual after many days; some- times the pus is in very small quantity, occupying only the apex of the pustule, the base remaining j broad, hard, and inflamed ; sometimes, more espe- ' cially on the hands and feet, the pus raises the cuticle over all the extent of the pustule, giving it the appearance of a bleb or bulla. Some of the I pustules are occasionally resolved, thin, white scabs forming successively over their surface; sometimes ulcerations, more or less deep, succeed the pustules, especially those seated on the lower extremities, or such as follow scarlatina or small- pox, and sometimes slight indurations succeed to the scabs. The pustules are not always distinct, but sometimes as it were confluent, and though generally accompanied with a burning, itching or stinging pain, they are also sometimes entirely free from any painful sensation. It has been doubted whether the term pustule was properly applied to the eruption of ecthyma, which supposes an active inflammation and sup- purative action to constitute the essence of the disease,—a supposition inconsistent with the state of system existing in all cases as the predisponent I cause of this disease ; and it has been asserted that a minute examination does actually disclose a state of vessels differing materially from such an | action ; that, instead, a lesion of some minute [ vessel takes place in each spot of ecthyma, and a [ kind of petechia? are thus produced. But from | some cause, depending either on a minor degree of debility of the system to that in which the | petechia? remain quiescent, or on a greater degree of irritability of the skin, attempts are made to repair the mischief by the vessels of the part, and inflammatory action takes place. The minute j vessel thus ruptured has its extravasated contents j mixed with the coagulable lymph poured out by the vessels labouring to repair the mischief, and the mixed fluids, drying on the spot, form the minuter scabs. But the constitution being un- equal to carrying through the process in a healthy manner, irregular attempts at suppuration take place, and the bulk of the scab is usually sur- rounded by and partly mixed with a minute por- tion of ill-formed pus, which, drying, increases the bulk of the scab. Many of the minute vessels concerned in this process being too relaxed, their secretion is mixed with and deeply coloured by red globules, which escape under the increased action. The scab now becomes a cause of irrita- tion to the surface on which its basis rests; the bloody purulent secretion increases, becomes in- spissated, and attached to the mass; ulceration gradually destroys the surrounding cutis, and the margin of sound skin becomes elevated and thick- ened. The scab, by the continuance of this pro- cess, is gradually elevated and rapidly enlarges, a fresher and broader ring of growth being added to its basis every three or four days. (Plumbe, on Diseases of the Skin.) This ingenious account of the process of the eruption of ecthyma is not in strict accordance with the phenomena, but, on the contrary, is in many respects at variance with them : it rests in its chief points upon suppositions purely gratuitous, for it has yet to be ascertained, and we are in- clined to deny it, that even petechia? are nothing more than ruptures of minute vessels; and it is directly contradicted by other observers who have examined attentively the structure of the pustules of ecthyma at the different stages of their progress. According to them, in their first state of red ele- vations, there exists only a vascular injection with a round circumscribed tumefaction 0f the skin • that, in their second state, a certain quantity of ECTHYMA. 739 purulent serosity is deposited, under the epidermis, at tneir summit, more rarely over all their surface ; that, in their third state, a substance of the nature ot a talse membrane is deposited in the centre of the elevation which is evidently perforated; that, in the fourth state, after this substance has been extracted and the epidermis removed, the pustule appears in the form of a little cup surrounded with a hard broad border; and that, in their last and fifth state, the border, during the following days, gradually disappears, whilst a small cicatrix is formed under the scab, the centre of which is sunk into the point where the perforation has been ob- served.* The phlyzacious pustules of ecthyma may be developed in the healthiest body by the local ap- plication of certain irritating substances. Thus tartar emetic, in powder or in ointment, after the manner of Autenrieth, is capable of giving rise to them ; and the same has been observed of certain pulverulent matters, as metallic powders, sugar, and lime, .which accounts for its being frequently seen in masons and grocers. But it is more commonly met with as a symptom and effect of a general disordered state of body, or a sympathetic consequence of irritation or inflammation of some internal organ. Hence "it has been observed to supervene upon unusual fatigue, long-continued exertion, much night-watching, great mental anx- iety, and strong moral affections : and it has been most frequently observed in persons who have in- jured their constitutions by previous excesses, by the abuse of spirituous liquors; or who have suf- fered in consequence of deficient nourishment, or unwholesome food, or surfeits; whose health has been impaired by dwelling in dark, damp, cold, and close habitations; or by habits of sloth and unclean ness; or whose constitutions have been debilitated by the effects of malignant fevers, as small-pox, measles, and scarlatina. Hence it is favoured by a moist and cold atmosphere, though it occurs most frequently in spring and summer, and is met with frequently in infants, in the de- cline of life, and in women, more especially during pregnancy, or whilst suckling, or coexisting with amenorrhoea; and is frequent in large cities, hos- pitals, prisons, garrisons, work-shops, and man- ufactories. For the same reason it is so often ac- companied with symptoms of gastric and intesti- nal disorders, with loss of appetite, pain in the epigastrium, irregularity of the bowels, lassitude, headach, &c.; and has been observed frequently coexisting with chronic inflammation of the mu- cous membrane of the stomach and intestines, with such concomitant symptoms as inflammation of the conjunctiva, and of the mucous membrane of the pharynx ; and has sometimes been observ- ed to be critical in acute gastro-enteritis. In pre- disposed habits, trifling local irritation will pro- duce it, as leech-bites, and even the friction of the clothes; so that some authors have remarked the pustules to be frequently seated under the wrist- bands and collar of the shirt, the waistband of the breeches, and at the gartering place above the knee. Though the eruption of ecthyma preserves its * Ecthyma, Dirtionnaire de Medecine et Chirurgie Pratique.—CA. Ed. Asselin Essai sur I'Ectbyma, Paris, 1627. character with comparative constancy, and is one l of those cutaneous affections the least convertible and disposed to pass into others, it sometimes de- | velopes itself in the exacerbations of other inflam- [ mations of the skin, as in lichen, prurigo, scabies, I and variola, but shows, in general, a closer con- nection with furunctdi. Though such is the general appearance, course, and causes of this disease, they admit, as we have noticed, of considerable diversity, sufficient, in a practical point of view, to justify a division of the genus into several species; and though we prefer the specification of Willan and Bateman to that of Alibert, (psoris Crustacea acuta and psoris crastacea chronica,) as being more true, precise, and practical, we shall venture upon a slight alteration of the name of one species, so as to make them all more distinct and consistent; and shall add to the genus the syphilitic form of the disease. The following will therefore be our arrangement. 1. Ecthyma vulgare. 2. Ecthyma infantile. 3. Ecthyma luridum. 4. Ecthyma febrile. 5. Ecthyma syphiliticum. 1. Ecthyma vulgare.—Syn. Epinyctis vul- garis (Sauvages); Psoris Crustacea acuta (AU- bert) ; Ecthyma aigu (Rayer) ; die gewohnliche eiternde flechte (Teutonice). In this species of ecthyma, generally after some days of languor and general oppression, of loss of strength and appetite, of derangement of the digestive functions, of headach, of pains in the bowels or of the limbs, and after less refreshing nights, with, more rarely, redness and inflamma- tion of the conjunctiva, and sore throat from ery- sipelatous inflammation of the pharynx, an erup- tion, accompanied with sharp stinging pains, ap- pears on some part of the extremities, or on the neck, shoulders, or breast. This eruption, which is usually completed in three or four days, con- sists of small red circumscribed elevations of the skin, not yielding or disappearing on pressure; for three or four days they continue to enlarge, becoming surrounded with an inflamed areola, which is hard and circular, and in young subjects of a bright red colour; having suppurated at their apex, which is distinguished by a small dark point, after a day or two they break, discharging first pus and afterwards a thinner fluid, which quickly concretes into dark-brown or greenish scabs. The constitutional derangement which pre- ceded the eruption is now abated ; the inflamed areola extends itself, becoming gradually paler as it enlarges; in about a week, all the pain, sore- ness, and inflammation subside, and the scabs soon after fall off, leaving no mark behind. If they continue adherent to the skin for a longer time, which sometimes happens, they leave, when detached, a dark red spot, or, more seldom, a su- ficial cicatrix, in size resembling those of small- pox, but less deep. If the pustules be situated in the neighbourhood of lymphatic glands, these latter become sometimes swollen and inflamed. The whole process of this eruption, in general, occupies from seven to fourteen days, and one eruption frequently completes the disease. This species is most commonly met with in 740 ECTHYMA. spring and summer; it affects principally young people and adults, and is occasionally observed in women during gestation. It frequently follows excessive fatigue, severe or prolonged exertion, night-watching, nurse-tending, anxiety, vexation, and other emotions of mind, errors of diet, and indulgence at table. It appears to be very much connected with the state of the digestive organs, but seems to depend upon something more than their mere derangement. It has been well ex- pressed by Bateman, by a state of distress of the constitution. It is also sometimes observed as critical of acute gastro-enteritis. In general, this species does not stand much in need of the interference of art. Gentle, cooling, and saline purgatives, as senna, manna, and tar- tarised soda or potass ; acidulous diluent drinks, as whey ; and light, cooling diet, afford ample means of cure. In robust, sanguine, or plethoric subjects, a small bloodletting accelerates the pro- gress of the eruption, and renders these means more efficacious. If much irritation and restless- ness be present, and much local uneasiness, the tepid bath is the surest means of affording relief. If the alvine evacuations are unhealthy, five grains of the pulv. hydrargyr. cumcreta may be taken at bed-time, with a few grains of Dover's powder, but even this is seldom necessary. The diluted sulphuric acid, simple or aromatic, is a good tonic as the disease declines. If the local affection de- mands any treatment, an emollient poultice is the best. 2. Ecthyma Infantile.— Syn. Terminthi neonatorum—Schlilhlasen, Teutonice (Plenck.) In infants of a constitution naturally weak, or disordered by bad or insufficient suckling, or by being brought up by hand upon food not suited to the powers of their digestion, an eruption of phlyzacious pustules is a common occurrence. In this species, as the former, the eruption is partial, chiefly affecting one particular part of the body, and, as in the former also, several pustules may appear together; but more commonly the disease consists of a successive eruption of indi- vidual pustules, by which its duration is some- times extended to several months. The pustules are first observed near the groins, on the abdomen near the umbilicus, near the axilla?, and on the thighs or nates ; sometimes they are not confined to the trunk and extremities, but also occupy the face and scalp. The course and progress of each individual pustule is the same as that of the ecthyma vulgare, but they are in general more irregular in their size, a large being frequently observed by the side of a very small one ; their form is circular, but they vary more in colour, being sometimes of a bright red, sometimes of an amaranthine, and sometimes of a livid colour, ac- cording to the strength or weakness of the infant. The pustules of this species are more disposed to suppurate extensively, and more apt to terminate in ulcerations, which in weakly infants heal im- perfectly, being covered by a thin, filmy cicatrix, easily re-opening or abraded, marked by a peculiar puckering of the surrounding skin. In some se- vere cases, generally only to be found amongst the most indigent, gangrenous eschars and deep sloughing ulcers, similar to those of erysipelas in- fantile, are not uncommon terminations of the pustules of this species. Occasionally, also, after threatening suppuration, the pustules gradually diminish and terminate by a succession of desqua- mations. The process by which an improper nourishment developes this di.sease appears to consist not only in a deranged state of digestion and assimilation, but also in the production of inflammatory affec- tions of the alimentary canal; for chronic inflam- mations of the digestive organs are frequently ob- served in connection with this eruption. But all the chronic derangements of the abdominal organs of infants are capable of inducing this eruption, and hence phlyzacious pustules are common symptoms of the marasmus which depends upon obstruction of the mesenteric glands. Cold and moisture appear frequently to furnish the exciting causes of this eruption. According to Plenck, it has sometimes prevailed epidemically. The treatment of this species consists in chang- ing the nurse or in altering her milk by diet or medicines, or in adapting the diet of the child te the powers of its digestion. For this last purpose, asses' milk, goats' milk, and whey afford very useful resources. The air, exercise, and clothing of the patient also deserve attention. In mild aperients, as castor-oil, manna, and magnesia, with mild mercurial alteratives and soda, and, if there be any feverishness or fretfulness, small doses of nitrate of potass and the tepid bath, the medical treatment consists. As soon as it can be borne, the ferrum tartarizatum, given in small doses, affords a convenient alterative and tonic. The chloruret of potass and the pyroligneous acid, both in small doses, are said to have been found particularly serviceable in this eruption, as, also, the Peruvian balsam and sulphate of quinia. Nor is the local treatment of the pustules, if large, un- important. If there lie much pain or irritation, fomentations of the decoction of poppy-heads fre- quently afford relief; in superficial ulcers, with profuse acrimonious discharge and itching, weak solutions of chlorine or chlorate of lime are most useful applications. 3. Ecthyma Luridnm.—Syn. Terminthus (Auctor. Var.) ; Psoride crustacee sordide (Ali- bert) ; ecthyma chronique (Rayer). An eruption of large phlyzacious pustules, some- times acquiring a very considerable size, having their base hard, elevated, of a dark livid red co- lour, and continuing highly inflamed, even after scabbing takes place; slow in their progress, ex- tensively distributed over the body, and generally connected with a slate of cachexy ; these circum- stances afford the distinguishing features of this species of ecthyma, which, though in different stages, is accurately represented in Plate xliii. of Bateman's Delineations, and in Plate liii. of Alibert. The pustule of this species is more analogous to an ill-conditioned boil, being more extensive and prominent than is usual in ecthyma. Suppuration is seldom completed in less than eight or ten days, when the pustules break and discharge a curdy, sanious, or bloody fluid, which is soon converted into hard dark scabs, and these are encircled with a hard violet or livid red-coloured areola. The surface covered by the scabs is slow in healing and the ulceration sometimes extends beyond the ECTHYMA. 741 Umite of the pustule ; but the ulcerated cavity is soon fi led up with hard dark-coloured scabs, hrmly attached, seldom separating for many weeks sometimes not tor months. Though the ulcer J tion extends, ,t Is alwavs surrounded . a . seated hardness and by a dark inflamed border, and, when not covered by a scab, which some- tunes happens it they have been removed by vio- lence, tedious ulcers, with callous edges, discharg- ing a sanious pus, are often the consequence. W hen the scabs fall off dark red-coloured patches, or cicatrices ot a violet red colour, remain for a considerable time over the parts which have been occupied by the pustules. Sometimes the pustules are long stationary, and do not proceed to suppu- ration, but are followed by tubercles of a violet colour; these may, however, ultimately proceed to suppuration and ulceration, and thus leave irregular cicatrices in the skin. In this species the pustules are more entirely independent of each other's progress, and may continue to succeed one another without any order lor several months. They are often attended with extreme pain and soreness, generally without fever ; but sometimes considerable constitutional irritation is present, and in protracted cases hectic fever : in some cases the respiration is remarkably affected. Ecthyma luridum is always a symptomatic affection, a consequence of cachectic disorder of the habit. For this reason, it prevails most during the winter season, and is most commonly met with amongst persons advanced in life, or amongst those whose constitutions have been broken down by misfortunes or imprudence. Hence the indi- gent who inhabit dark, damp, and narrow streets and cellars, whose means and habits seldom allow them ihe comforts of cleanliness; prisoners con- fined to dark and dreary dungeons, filthy, squalid, and ill-.ed ; those who have been exposed to great hardships and hard labour; or those who have been compelled to live upon unwholesome food, particularly such as is hard, dry, smoked, and salted; and such as have abused their health by an irregular life, particularly those addicted to the use of ardent spirits, are most frequently the sub- jects of this disease. The state of body which prepares for this disease may also be produced by previous diseases, as in febrile affections, when the cure or the crisis has been imperfect; aftd in this way it occurs very frequently as a sequel of scar- latina, measles, and small-pox. The essential point in the treatment of the ecthyma luridum consists in correcting the faulty st*te of habit upon which this disease depends, Mid this object, the cure of the cachexy, is not to be attained by any one simple method of treat- ment, but by the combination of several,—neither by depuratives, nor alteratives, nor tonics, but by a happy adaptation and adjustment of them all. The experienced physician knows, that to renew and regenerate the organizing and organizable fluids of the body, before proffering a supply it is necessary to excite a demand, and that to give vigour and activity to the function of nutrition, it is useful to diminish the volume of the nutritive fluid; that, whilst in this way activity is given to th* process of nutrition, care should be taken to modify, by the proper use of alteratives, the action of the organs, by whose united functions the nutritive fluid is created ; and that these actions may be performed satisfactorily and effectually, it is necessary by stimulants or tonics to support the action of the nervous system, until the new, fresh, and healthy blood is of itself capable of doing so. In these three intentions, the indications of the cure of cachexy consist. Therefore, in the com- mencement of the disease, mild cooling purgatives, or very small repeated bloodlettings, (from two to four ounces,) and light nutritious diluting drinks, are good preparatory measures; whilst any dis- tressing irritation may be relieved by opiates, the action of any organ which is deficient may be solicited or modified by its appropriate specific stimulus, and the vigour of all may be increased by exalting artificially that of the nervous system. From this view the practitioner will readily under- stand the application of such remedies as sarsapa- rilla, guaiacum, and taraxacum; of saline mineral waters; of antimony and mercury, either alone or as they are more conveniently united in Plum- mer's pill; of vegetable and mineral acids, of decoction of cinchona, of sulphate of quinia, and chalybeates ; of the fresh and sea-water tepid bath and cold sea-bathing; of whey, asses'milk, milk diet; of food, light, nutritive, and easy of diges- tion ; of wine in small quantities; of gentle exer- cise in open dry air; of warm clothing; and, as much as may be possible, of quiet and repose of mind. The local treatment, when the state of the pus- tules demands it, consists in emollient applications and softening plasters to favour a benign suppu- rative process; but when they show any malig- nant appearance or disposition to gangrene, it is best arrested by nitrate of silver in solution, the butter of antimony, or caustic potash. 4. Ecthyma Febrile. — Syn. Ecthyma ca- checticuin (Bateman); Psoris Crustacea acuta (Alibert) ; Ecthyma aigu (Rayer). After febrile symptoms of two or three days' continuance, accompanied by headach, pains of the limbs, loss of appetite, disordered digestion, irregularity of the bowels, great restlessness, and sometimes delirium, there appears an eruption of numerous and scattered phlyzacious pustules, ge- nerally smaller than in the other species. The pustules are commonly first observed upon the extremities, to which, either dispersed or clustered together in irregular patches, they are sometimes confined ; but they also frequently appear first upon the breast, in other cases on the forehead ; and sometimes extend over the whole trunk, the face, and the scalp. The eruption of the pustules is accompanied with a burning stinging sensation, or with itching or tingling, and a great desire to relieve it by scratching. After the first eruption fresh pustules continue to break out daily, until the skin is thickly studded with them ; and as the successive pustules go through their different stages of inflammation, suppuration, and desqua- mation, at similar periods after they arise, they are necessarily seen under all these conditions at the same time; the rising pustules exhibiting a bright red hue at the base, which changes to a purple or chocolate tinge as the inflammation de- clines, whilst little laminated scabs are formed upon their tops : when these fall off, a dark stain is left, which remains for some time. The pus- 742 ECTHYMA. tules which occupy the breast and abdomen are generally less prominent than those on the face and arms, contain less matter, and terminate rather in scales than scabs. Pustules may continue to succeed each other, in the manner just described, for several weeks, the average duration of the dis- ease being from two to four months. The best representation of this species of ecthyma is that in Batcman's Delineations, Plate xliv. On the appearance of the eruption the febrile symptoms are diminished, but not removed, for a state of constitutional irritation, of erethism, or hectic, continues during the progress of the dis- ease, which is invariably accompanied by great languor, and by much depression both of the spi- rits and muscular strength. The pulse is gene- rally quick and small; the skin hot, dry, and harsh ; the tongue dry, red, and glazed; the gums tender, swollen, and bleeding easily, sometimes to a considerable extent; and there is generally an inflammatory state of the fauces and pharynx, in which superficial ulcerations may be observed ; this inflammatory state sometimes extends to the Schneiderian membrane and conjunctivae. The legs and feet are occasionally oedematous. The ecthyma febrile is always a symptomatic disease depending upon an inflammatory state of the mucous membrane of the stomach, and con- nected with a digestive state of the abdominal cir- culation, corresponding to that disorder of body described by writers under the term of scorbutic cachexy. In persons of this state of body this eruption declares itself at the change of season, in spring and autumn, from exposure to inclemen- cies of weather. It occurs most frequently after the body has arrived at full maturity, particularly in those debilitated by a long series of excesses ; and it is occasionally seen in the crude convales- cence of gastritis imperfectly cured. The nature of the ecthyma febrile affords satis- factory indications for its cure. If the eruption be extensive, the local inflammation severe, or if it be attended with much fever, depletion by small venesections, by leeches to the anus, epigastrium, or hypochondriac regions, or by cooling saline purgatives, is a necessary measure; whilst the secretion of the liver is to be solicited by mild mercurial alteratives, taking care to prevent their affecting the constitution,—a circumstance, how- ever, liable to occur in this disease, even ftom very small doses. The mercurial alterative may be combined with antimonials, as the James's pow- der, or with Dover's powder. These, with the tepid bath if there be much irritation, diluting acidulous drinks and light diet, constitute the means of cure. In milder cases, cooling saline purgatives and acidulated drinks will, in the com- mencement, be found sufficient; and when the febrile symptoms have abated, the Plummer's pill combined with a course of taraxacum affords an alterative treatment of great value. These remedies may be succeeded by the di- luted sulphuric acid and preparations of cinchona, as soon as the state of the stomach admits them. The warm alkaline or salt-water baths are very useful subsidiary means, and the diet throughout should be mild, light, easy of digestion and nutri- tious. When the pustules are the seat of much pain, of itching, or uneasiness, local applications are of considerable use. Of these a solution of chlorate of soda is one of the be-t. Dr. A. T. Thomson found great advantage from the following : R Plumbi acetatis, ^ss. Acid, hydrocyan, f.^iii. Unguenti cetacei, £'m. M. fiat unguentum partibus cutis nudis appli- candum. The ecthyma febrile has only been accurately described by Bateman, Alibert, Hewsou (North American Medical and Surgical Journal, January, 1826), and Dr. A. T. Thomson (Bateman's Sy- nopsis, 7th edit. 1829). 5. Ecthyma Syphiliticum.— Syn. Syphi- lide pustuleuse phlyzacree (Rayer, Biett); Pus- tular venereal disease (Carmichael). Under the influence of the venereal virus, modi- fied no doubt by some peculiarity of constitution, natural or acquired, an eruption of phlyzacious pustules is frequently observed ; and which, in a classification founded entirely on the external characters of disease, we are justified in placing under the genus ecthyma. The pustules of the ecthyma syphiliticum suc- ceed each other, are generally sparingly scattered and distinct, and seldom very numerous, and have been by Lagneau, on account of their large size, compared to those of small-pox ; they are most frequently seated upon the limbs, and especially upon the legs; but they have been observed upon every part of the body. They first appear under the form of a livid spot, in breadth somewhat less than that of a shilling, but also sometimes larger; throughout a considerable extent of this spot, the epidermis becomes raised and gradually distended by a greyish sero-purulent fluid, whilst the tume- faction slowly increases, and is surrounded by a broad areola, invariably of a livid copper colour, one of the characteristic distinctions of this species of ecthyma. After a few days the pustule opens and discharges a liquid, which concreting forms a very hard blackish or brownish-black scab; the scab becomes by degrees very thick, furrowed circularly, and is generally of a regular round form. The progress of the pustule most commonly takes place without any symptoms of local inflam- mation ; there is little increase of heat; the sur- rounding parts are free from pain ; a slight smart- ing is all that the patient feels. The scabs are strongly adherent, and they may remain unde- tached for an indefinite time; but when they fall off, either spontaneously or by means of emollient applications, they expose round ulcerations, most commonly deep, having their edges abruptly pre- cipitous, formed of a hard violet-coloured tissue, and their bottom of a greyish, pale, unhealthy aspect. These ulcerations seldom extend, but the scab gradually forms again, and is successively detached ; until at last, by means of appropriate treatment, the new scabs are formed less thick, the ulcerated surfaces become healthy, and are succeeded by a permanent round cicatrix, of a copper colour. (Cazenave et Schedel, Abrege Pratique, &c. Paris, 1828.) Infants born infected with the syphilitic virus present most commonly this form of eruption. In this case the pustules are very numerous, broad, flat, superficial, and of an oval form. They be! ECTHYMA —ECZEMA. 743 come covered with blackish scabs, of no great thickness which are followed by small ulcerations. A very characteristic general appearance of the countenance, which it would be difficult to de- scribe, attends this complaint. The skin is foul, the features are drawn, and the whole body is emaciated, wan, and, as it were, etiolated ; the countenance is wrinkled, giving the appearance of extreme old age, and a peculiarly diseased odour is exhaled. (Cazenave et Schedel, Op. cit.) v The pustules of the ecthyma syphiliticum are distinguished from those of the other species by being surrounded by an areola less broad, but of a dark copper or violet colour; by their thicker scabs, furrowed circularly ; by being succeeded by ulcers round and deep, with precipitous edges, and being invariably followed by a depressed in- delible cicatrix, and by being generally attended by some concomitant constitutional symptoms, such as inflammation and superficial ulcerations of the fauces, pains of the bones, sometimes iritis, whilst the history of the case affords the evidence of some primary affection. Mr. Carmichael, who is peculiar in his opinions in limiting the true syphilitic disease to one form of eruption, does not consider the phlyzacious pustules to be of that nature. He considers them as consecutive of a peculiar primary ulcer, which he describes as characterized by a reddish-brown surface, bordering closely on the phagedenic cha- racter, having its edges raised and well defined, not excavated, but either on a level with the sur- rounding skin or considerably raised above it, ap- pearing at its commencement in the form of a small pustule, attended with itchiness. According to his observation the secondary eruption is pre- ceded by fever. (Carmichael on Venereal Dis- eases, 1825.) The view which Mr. Carmichael entertains of this eruption leads him to consider mercury as unnecessary for its cure; he therefore depends upon antimonials, sarsaparilla, and guaiacum for the constitutional remedies ; zinc lotions and rest in the primary affection ; sulphur fumigations, or equal parts of tar and sulphur ointment as the local remedies in the secondary eruption. But as this method of treatment has not met with general sanction, the greatest number of practitioners think it safest to have recourse to the specific cure. This has been already described at length under Acne Syphiliticum. (See Acne.) [This form of ecthyma, as well as that which attacks chiefly the legs of old and cachectic per- sons who have lived intemperately, is well treated by the iodides, especially the iodide of iron.] When an infant at the breast is the subject of this eruption, the remedy should be introduced through the system of the nurse, either by admi- nistering to her the liquor oxymuriatis hydrargyr., or by the friction of mercurial ointment; and if the health of the nurse does not allow of this manner of introducing mercury, the same may be effected by giving the infant the milk of a goat which has been submitted to the friction of mer- curial ointment. These methods have been used at the Hospital of St. Louis at Paris, and followed with the most complete success. But the mercury, if necessary, may be also directly given to the in- fant ; either small doses of the hydrargyrum cum creta, or minute doses of the oxy muriate of mer- cury in decoction of elm bark or emulsion of bitter almonds, as recommended by Dr. A. T. Thomson. (Bateman's Synopsis, 7th edit.) T. J. Todd. ECZEMA, (from £«£&■>, effervesco,) is a disease of the skin, characterized at its commencement by the existence of minute vesicles, which are usually closely crowded together, and terminate either in the absorption of their contained fluid, or in its effusion and subsequent concretion into thin scales. It is accompanied with a burning heat and tingling of the inflamed portions of the skin. The disease is not contagious, is usually unattended with fever, and may, for the most part, be traced to some irri- tating cause, either acting directly on the cutaneous surface, or internally through the medium of the constitution. Willan and Bateman, who have always endea- voured to seize, on the earliest appearances pre- sented by cutaneous diseases, as being the most constant and characteristic, have placed eczema in their sixth order, vesiculx; whilst Alibert, whose classification is usually founded on the more obvious, though less distinctive, phenomena occur- ing in the advanced period of these affections, a period when several species which were originally dissimilar often become confounded in their exter- nal features, though still unlike as to their even- tual progress, and as to their appropriate modes of cure, has placed it in his order « dartre squam- meuse." Thus he has grouped it along with some of the true scaly diseases, and along with some of the papular ones. Struck, however, by the abundant serous secretion by which it is usually moistened, (and which should have led him to a knowledge of its essentially distinct nature, by turning his attention to its primitive vesicular form, the source of this moisture,) he adds the characteristic epithet " humide." M. Biett, who, to an intimate acquaintance with the labours of his own countrymen in this department of pathology, adds an extensive know- ledge of the works which have appeared on the subject in England and Germany, usually mani- fests a decided preference for the classification and general views of Willan and Bateman. But in respect to eczema, he thinks these authors have too many subdivisions of the disease, and have spoken in too sweeping a manner of the absence of inflammation around the vesicles, and of fever; as the former almost always exists to a certain extent, and if the local affection occupies much space, some fever usually results. The latter fact, however, we think is very plainly hinted at, if not expressly stated, by Bateman himself. If the cutaneous affection be very severe and extensive, we often also find inflammation of the mucous membranes to coexist. Rayer, a more recent writer, whose views often manifest a somewhat singular coincidence with those which Biett has been in the habit of pub- licly teaching for many years past, emits the same opinion as to the unnecessary subdivision of this affection in the English classification, and pro- poses to substitute a two-fold division, viz. into acute and chronic, as more practical and useful 744 E C Z E in a . than the triple one into eczema solare, eczema im pet iginodes, and eczema rubrum; against which, in addition to the want of uniformity in the grounds on which it is formed, it may be objected that the first and third are really the same disease, differing only in respect to their cause, or the degree of attending inflammation; and against the second, that it is really a complication of two diseases, and not a distinct, well characterized, simple species. Averse, however, to interfere with an arrangement so universally adopted in these countries as that of Willan and Bateman, we shall not here deviate from it, convinced that in pathology as well as in pharmacy, the modern taste for uniformity and simplification of nomen- clature, whenever it has deprived us of terms recalling well-marked sensible characters, effects or causes, has tended to do injury to a science so strictly practical as that of medicine. Names that make a strong impression on the memory are here often much more desirable than those whose only merit is their consistency with a purely scientific but unimpressive uniformity. Eczema most frequently appears simply as a local disease, preferring, unlike the true scaly dis- eases, those situations where the sebaceous follicles abound, as the ears, axillae, groins, upper and inner part of the thighs, scrotum, margin of the anus, and in women, moreover, the external parts of generation, the nipples, and adjacent portions of the breast; or it selects those parts which are much exposed to external influences, as the hands, arms, and face. At times, however, it is a much more extensive di.sease, and occupies successively nearly the whole cutaneous surface; and this is especially the case when it originates in the use of mercury, or in some other cause acting through the medium of the constitution. 1. Eczema Solare chiefly occurs in persons of a delicate skin, after long exposure to the rays of a summer sun. Sportsmen, and those who take very long walks in this season, mowers, harvest- labourers, and others whose business exposes them to the above cause, are its most frequent subjects. It is occasionally preceded by a slight feeling of general indisposition; and some degree of tension, together with heat and tingling, is felt in the por- tion of skin which is to be the seat of the erup- tion. This is most commonly the backs of the hands and fingers, and the face, neck, and arms, especially in women, or those who happen to have them long uncovered whilst in the sun. The skin is usually pale, and is crowded with thick-set microscopical vesicles, so closely approximated as to leave no interstices of redness. Occasionally, however, there is a slight blush round each vesi- cle; and this species occurs usually, as Bateman mentions, in the upper part of the arms or on the breast, particularly in females, and is commonly called heat spots. In men of a sanguineous tem- perament who use violent exercise in hot weather, phlyzacious pustules, or painful and slowly suppu- rating tubercles not unfrequently make their ap- pearance in the midst of the eczematous eruptions. The vesicles are very small and acuminated, and contain a limpid fluid, which soon becomes milky and is absorbed ; or after slightly increasing in size, they burst and effuse their contents, which concrete and form minute brownish yellow scales or scabs, and tho whole disease, if not very exten- sive, finally terminates in desquamation within one or two weeks from its commencement. The larger the surface at first attacked, and the trreater the irritation, the more likely is the affection to spread successively to new and extensive portions of the cutaneous superficies. Some precursory indisposition, as we have just stated, may occur, but much more frequently it is absent, the eruption coming out almost immediately after exposure to the sun's rays. It usually begins and terminates in an acute form, but at times it passes almost immediately into a chronic inflammation, with an abundant exudation of a viscid fluid, which rapidly concretes in the form of thin scales, and is attended with tenderness, redness, and excoria- tion of the affected skin. In these prolonged cases, as Bateman remarks,- the effused fluid seems to be of an acrid nature, inducing inflammation, and occasionally superficial ulceration of the parts with which it comes in contact, and the disease assumes somewhat of the form of impetigo. The duration of this affection seems to be little under the influence of medicine, and usually requires little more than the protection of the part from the exciting cause, and the frequent employment of tepid ablutions. 2. Eczema impetiginodes is preceded and accompanied by a painful tension, formication, and pruritus, and is distinguished from the other varieties by the occasional intermixture of pus- tules, into which its vesicles, which are deeply imbedded in the skin, become themselves not un- frequently converted. All this gives it a conside- rable resemblance to some of the forms of impe- tigo, to which it is also allied in the similarity, or rather the identity, of its causes, which for the most part consist in the habitual contact of vari- ous irritating matters. Thus the irritation in- duced by the repeated application of lime, sugar, alkalies, &c, to the hands, gives rise to eruptions, (bricklayer's itch, grocer's itch, &c.,) which are vesicular in some individuals and pustular in others, and are apt to assume a chronic form when the exciting cause long continues to be applied. Thus, also, either a vesicular or a pustular inflam- mation may be induced by the irritation of sul- phur or sulphurated alkalies, used for the cure of common itch, and be mistaken for the continuance of this disorder. Similar eruptions may be caused by a blister, a mercurial plaster, Indian varnish, valerian root, diachylon, frictions with croton oil, opodeldoc, or ammoniacal liniments, and many other stimulat- ing external applications. Exposure to the heat of a forge or a strong fire has sometimes excited it, as has likewise the internal use of various me- dicinal substances, as opium, antimony, copaiba, &c. Irregularities in diet and excessive drinking are also reckoned amongst its occasional causes. When the skin is very delicate, this eruption has been known to manifest itself within three or four hours after the application of a Burgundy pitch plaster, and to be productive of much distress. We have known an individual in whom almost every species of plaster, even the mildest and least irritating, has given rise to this affection, and have seen it ensue in another after the employment of the common linseed poultice. The mixed erup- ECZEMA. 745 ion of vesicles, pustules, and boils occasionally i pain, by coming in contact with the excoriated induced by a blister or other irritating plaster, surface, which in some cases is so extensive as to olten extends to a considerable distance from the occupy the greater portion of the body. When centre of irritation, overrunnin-r a considerable por- so widely spread and severe, it causes much suf- tion of the chest, back, abdomen, &c, inducing ferinsr, and a certain degree of febrile excitement much pam and feverishnfss. and persisting occa- is necessarily the consequence. sionally, as Bateman remarks, for a fortnight or It usually makes its lirst appearance about the upwards, but without any eventual injury. ' scrotum or inner part of the thighs or groins, but The eczema impctiginodes, if its extent be not ! this is not constant. Its duration is indefinite. If great, may run throu >h its course in from one to . three weeks. Occasionally, however, it passes into an obstinate pustular or scaly disease, and ; this we have seen it do within a fortnight after its commencement. In ite ordinary course, the vesi- i cles break and discharge an acrid fluid that irri- I tates the adjacent skin, whi.-h becomes inflamed, thickened, fissured, and excoriated in streaks, as j if torn by the nails. At this period its resem- ] blance to impetigo is still more striking than at an earlier stage. In the treatment of this affection, in addition to the removal of the irritating causes, and the use of the antiphlogistic and local soothing mea- sures to be detailed at the end of this article, we must at the same time endeavour to remove that morbid state of the system of which the prone- ness to these eruptions from slightly irritating causes is an evidence ,- and it is in this part of the treatment of cutaneous disorders that the French practitioners, who have anticipated and excelled us so much in the employment of the antiphlo- gistic and soothing measures just alluded to, ap- pear to have fallen short; the proper attention to the regulation of the functions of the digestive organs being too often overlooked by them. The most remarkable instances of this extreme irrita- bility of the skin which we have met with, have been in individuals labouring under dyspeptic symptoms of an old date; but we do not by any means wish to insinuate that this is universally the case. Eczema impetiginodes, as well as im- petigo itself, seems to fall under the head of dar- tre squammeuse crustacee in Alibert's arrange- ment. 3. Eczema rnhrnm is the most severe and most inflammatory variety of this affection, and is, like the others, preceded by a feeling of stiff- ness, heat, and tingling. It takes its specific name from the diffuse or erythematous redness on which the vesicles make their appearance. At first it has somewhat of the appearance of erysipelas, but may be easily distinguished from it by the 'oughness which it presents to the touch, and which, on minute examination with a lens in a favourable light, is found to depend on the pre- sence of innumerable small and crowded transpa- rent vesicles. These in two or three days become opalescent, and in size about equal to a pin's head, after which they usually burst and pour forth their contained fluid, which inflames and excori- ates the parts with which it comes in contact. The disease successively invades new portions of the skin, and is accompanied as it proceeds with Hwelliiv of the true skin and cellular membrane The discharge from the vesicles is often very abundant, has a peculiarly heavy odour, and con- cretes rapidly into yellowish incrustations. Hard- ening on the patient's linen also, it causes much and bloody expectoration Vol. I. —94 3n limited in extent, it may run through its course within a fortnight; but if it has occupied the greater part of the surface of the body, it may last for a couple of months or even longer, when at length the encrusted secretion drops off. But the morbid cuticle continues to exfoliate for a consi- derable time after, and this is occasionally attended with the loss of the hair arid nails. Of thisjaffec- tion, mercury is one of the most frequent causes. The mercurial eczema (sometimes miscalled ery- thema) seems to have been first clearly noticed by Benjamin Bell, in his treatise on Gonorrhoea and Lues Venerea, and was subsequently more fully investigated by Dr. Moriarty, Dr. Spens, and Dr. M'Mullen, and by Mr. Alley and Mr. Pearson. Dr. M'Mullin's description of it, in the second volume of the Edinburgh Medical and Surgical Journal, represents it as a much more serious affection than Bateman and most succeeding writ- ers have done. According to Dr. M'Mullen, it is ushered in with a well-marked febrile paroxysm, and is accompanied by dry cough, difficult respi- ration, and sense of tightness across the pracordia —the skin being remarkably hot and the seat of an itching and prickly sensation. On the first or second day, a diffused redness and numerous crowded papula? (vesicles) make their appearance, generally on the scrotum, thighs, or forearms first, or on those parts where mercurial frictions have been made. The cuticle soon exfoliates, and the fauces and eyes become somewhat inflamed. The above symptoms, which, according to Dr. M'Mullin, characterize the first stage, last for one or two weeks, and it the disease be in a mild form, recovery may ensue immediately after the desquamation; but if severe, a second and much more serious stage ensues, in which the skin is studded with innumerable vesicles, which soon discharge an irritating fluid of a nauseous odour. This, by concreting into large incrustations of a reddish or dark colour, constitutes the third stage. The inflammation of the fauces, eyes, and eye-lida now becomes exasperated, and the face is deformed by a mask of encrustations fissured in various directions. The affection occupies successively a large surface of the body, which in its excoriated state is the seat of great irritation, and the pain ia exasperated by the weight of the body in lying, as well as by the contact of the concreted matter. The latter is liable to crack or be torn across on the slightest change of posture, and thus new raw surfaces are continually becoming exposed. A fever of the typhoid type accompanies these ex- treme cases ; yet, which is singular, the appetite continues unimpaired throughout. The catarrhal symptoms generally undergo an exacerbation to- wards the conclusion, as is manifested by the in- creased anxiety and pain in the chest, the cough. The pulse become) 746 ECZEMA. frequent, feeble, and irregular, the tongue black | •nd parched, and diarrhoea, delirium, convulsions, gangrene of the skin, and death close the scene. I In the above description we scarcely recognize the comparatively mild disease described by Bate- man, whose account certainly agrees much more | olosely with the affection usually met with in practice. In mercurial eczema, in addition to the catar- rhal affection of the air-passages, a tendency to in- flammation in the mucous membrane of the intes- tines often coexists, as is manifested by the facility with which diarrhoea, is induced. Dysury too is an occasional but much rarer symptom. The ca- tarrhal affection is not mentioned by Bateman ; and by some other writers, who speak of it, it is considered to be merely a casual complication. Dr. Gregory thought that both the affection of the skin and that of the mucous membrane were the effect of cold caught whilst under mercurial influ- ence ; but Mr. Pearson's experience does not con- firm this opinion. Rayer strangely intimates that the occurrence of eczema mercuriale may be obvi- ated by taking the precaution of shaving the part to which mercurial frictions are to be made. When we recollect, however, that it may be induced by almost every form of mercurial medicine, and that too whether internally or externally administered, we cannot place much confidence in this mode of prevention. That inflammation of the skin should result from the internal exhibition of mercury, is in no respect more wonderful than that severe and even fatal enteritis should originate in its external employment, as in the instances recorded by Dr. Crampton. Those cases of eczema rubrum which originate in the use of mercury, are generally the most ex- tensive. Local examples of it on exposed parts seem to be sometimes induced by the influence of very hot weather, and a succession of red patches generally make their appearance in such a man- ner as to prolong the disease to several weeks, without, however, any evident derangement of the general health. Amongst its occasional causes have been reckoned, a stimulating diet, the con- stant use of shell or sea-fish, &c. Some indivi- duals are subject from slight or inappreciable causes to a very frequent recurrence of this affec- tion about the ears, face, and back of the neck, accompanied with swelling and redness of the face, and a considerable puffiness about the eye- lids; which obtain for it in popular language, but very improperly, the appellation of erysipelas, from which it differs both in its duration and the degree of danger attending it, as also in the pre- sence of vesicles in place of bullae. Occasionally minute pustules are intermixed with the vesicles, and make the eruption approximate more closely to the description of the impetiginous variety of eczema. Eczema in its chronic form, which often proves a very intractable disease, (its removal, especially in elderly persons, being attended with great diffi- culty, and its relapses frequent.) has perhaps not been sufficiently attended to by Bateman. According to Rayer, who has given an excellent description of it, it may occur as the sequel to any of the acute varieties above described. In it the inflammation often extends deep into the true skin and cellular membrane, giving rise to a thicken- ing, roughness, and inequality of the surface, which becomes fissured and excoriated, and is not unlike a part which has been lately blistered j being raw and moist in some points, and present- ing a scurfy appearance from adherent cuticle or dry and foliated secretions in others. It is in this advanced stage of eczema that its identity with the dartre squammeuse humide of Alibert is most obvious. The secretion of acrid lymph is uninter- rupted, and the itching so intolerable, that the unfortunate patient cannot abstain from tearing the surface with his nails, and thus aggravating and perpetuating the disease. This state may continue with little variation for months or even years; the cuticle, which assumes a yellowish tinge from the contact of the discharge, being at frequent intervals exfoliated in large patches. The inflammation is liable to frequent exacerbations; and occasionally, after appearing to be almost subdued, it bursts out with increased violence, either on the same place, or in some dis- tant part of the body. One of the most frequent seats of chronic eczema is about the external ears, and from thence it not seldom extends into the meatus auditorius exter- nus, and thus sometimes induces deafness. In like manner, when it exists on the face, it may spread from the external surface of the nose to the nostrils; and in both this and the preceding case it proves peculiarly obstinate. When seated on the lips, they occasionally become considerably swollen, and we have seen it in this state present an appearance which might in young persons have been mistaken for a scrofulous affection. When it attacks the scalp, it is not unfrequently confounded with tinea. There is great itching. The hair is at first matted together with the abundant discharge, but this, gradually diminish- ing, is succeeded by a constant furfuraceous desquamation, beneath which the skin on examina- tion is found to be red, shining, and tender. In its chronic form, eczema frequently manifests itself also on the upper and inner part of the thighs; the scrotum and prepuce in men, and about the external organs of generation and the breasts in females; and in all these situations the itching is most intolerable. The circumference of the anus is also very fre- quently attacked with it, simultaneously or alter- nately with other parts of the body. It often occurs here by an extension of the disease from the scrotum or thighs ; but in some of the most obsti- nate examples it is a strictly insulated affection, confined to the verge of the anus, perineum, and cleft of the buttock; in which situations a serous secretion concreting into thin, laminated, semi- transparent scales, like exfoliated cuticle, takes place at intervals. In these cases it seems often to be connected with dyspepsia and an irregular stale of the bowels, the stools being unnatural, and affording evidence of vitiated intestinal and biliary secretion, inasmuch as they are often peculiarly fetid, black, and tenacious, and expelled with so much difficulty, as to give rise to the belief in the existence of a stricture of the rectum. But this difficulty seems to depend merely on a spasmodic state of the sphincter, induced by the chronic irri- tation in the skin and contiguous portion of the ECZEMA. 747 mucous membrane of the rectum , for the patient is at times able to evacuate the bowels freely. The empirical use of bougies in such cases cannot fail greatly to aggravate the patient's sufferings and perpetuate the evil, by the forcible extension of the excoriated parts. The sensation of burning heat and itching becomes greatly aggravated on getting warm in bed, demanding all the resolution which the individual can summon up to avoid scratching and exasperating it with his nails, an operation which in his sleep almost inevitably takes place. 1 he exacerbations to which this affection is liable sometimes alternate and sometimes coincide with those of the dyspeptic affection. It is one of the many examples of the intimate sympathy which subsists between the external outlets of mucous membranes and the more internal and distant parts of their surface. Ascarides sometimes coexist with this disease, and though there is no reason to suppose them capable of producing it, save when a peculiar predisposition exists, they must doubtless tend much to exasperate the irritation and prolong its existence. We have known this affection alternate with small patches of lichen, psoriasis, or eczema on the arms or neck. Se- dentary habits, too free a mode of living, especially in regard to the use of wine and malt liquors, and costiveness, are sure to aggravate it. With regard to the treatment of it, little can be expected from local applications; frequent ablution with cold water affords a momentary relief; but it is to great temperance, steady and active exercise, a due regulation of the bowels, and a correction of the vitiated and irritating nature of the alvine dis- charges, that we can alone look for permanent benefit. The diagnosis of eczema is occasionally at- tended with considerable difficulty, as cases not unfrequently present themselves where papula? and pustules coexist with the true eczematous disease; thus allying the case at once to lichen, impetigo, and eczema, and making us wish that the idea of Burns had been acted on, in establish- ing as an appendix to our present classification a set of composite genera to which those specimens of cutaneous disease which are of a mixed charac- ter, and display an affinity to two or more of the simpler forms, might be referred. For the conso- lation of the student in this department of patho- logy, we may mention that we have seen the most practised eye puzzled by such combinations; and individuals, who had made cutaneous disorders their peculiar study for years, confess themselves unable to dispose satisfactorily of such examples in any part of our present arrangements. In the first stage of the affection, when it exists in its simple form, the only diseases with which we are liable to confound it are some of those of the papular kind, and scabies. From the former it may be satisfactorily distinguished by the colour of the minute vesicles, or more certainly still by puncturing them with a needle, and thus demon- strating the fluid nature of their contents. Their subsequent progress, too, is dissimilar. From scabies, or common itch, the diagnosis, especially of the impetiginous form of eczema, notwith- standing what is asserted by professed writers on the subject, we have often found by no means •asy. Its preference for those situations where the sebaceous follicles abound—a knowledge of the preceding causes, such as exposure to great heat or other local irritants — the closeness and uniformity with which its minute and acuminated vesicles are distributed,—the accompanying tume- faction— the tingling and smarting rather than itching which attends them — will, it is said, ena- ble us to distinguish it from the scabies, in which the vesicles are more apart—larger and more un- equal in size—less transparent, or of a duller co- lour, and without any inflammation at their base, —intermingled with minute ulcerations and small dark scabs—attended with a sensation of simple itching—and, finally, occupying chiefly the inter- vals of the fingers, the wrists, and the flexures of the articulations generally. The presence or absence of a contagious quality, and the effects of treatment, which are usually dwelt on as points of distinction, are not very creditable grounds on which to form our diagnosis. To discover the nature of a disease when it has been already cured, or when it has spread to other persons in consequence of our incompetence to decide on its true nature, is not satisfactory to any of the parties concerned. A complication of itch and eczema is not an impossible occurrence, and of course must present much difficulty. Indeed, we have heard of such cases by which the medical attendants were greatly embarrassed, till in the frequent handling and ex- amination of the parts they have themselves con- tracted scabies, and thus become fully convinced of the existence of at least one part of the dis- order. The miliary eruption may be easily distinguish- ed by the constitutional symptoms which precede or accompany it; and simple erythema, by the absence of all feeling of roughness such as char- acterizes eczema rubrum even in its early stage, and depends on the elevation of the nascent vesi- cles. Inattention to this circumstance has led some writers improperly to describe the eczema mercuriale as a species of erythema. Impetigo is sometimes distinguishable with difficulty, if at all, from that species of eczema in which pustules present themselves. The existence of pustules from the very commencement, and the greater thickness and prominence of the crusts, belong more, especially to the former. In a practical point of view, however, their diagnosis is not very important. It is often far from easy to distinguish psoriasis of the scrotum and penis from eczema of the same parts when in its advanced and scaly stage : the greater thickening and hardness of the integuments in the former, and the fact of vesicles or humidity never having been present, will aid our diagnosis. When eczema has existed a con- siderable time, its red, chopped, and scaly surface approximates closely to the appearance of lichen agiius. But even when vesicles no longer exist, as is the case in the more advanced and drier stages of eczema, minute disseminated scaly points will frequently show their former seat, and dis- close the true nature of the disease. Eczema of the breast and nipple in its scaly stage, which it has generally attained to before we are consulted, presents to the eye merely a collection of thin and generally yellowish crusts, and is accompanied with a burning itchiness; at this period we shall 748 ECZEMA. in vain search for vesicles. Chronic eczema, in- deed, in its later periods, when it has passed into a scaly state with numerous erosions and ulcera- tions, is scarcely recognizable at first sight, even bv the most experienced eye. It is to the history of the case that we must here look for decisive information. In what we have said of the diagnosis of this very frequent and very distressing cutaneous af- fection, we have been actuated by a desire to re- present it in all its true difficulties; as we know that the most zealous students often turn with disgust from the investigation of diseases of the skin, upon finding these difficulties so infinitely greater than they are represented in books, and begin in despair to suspect that they want the tact necessary for their successful study. When made aware of the obscurity which they often present even to the most experienced, this cause of discouragement will in some degree be done away with. The prognosis of the acuter forms of the dis- ease, especially when they depend on some obvious cause of local irritation, is generally favourable. In those cases where the mercurial eczema has as- sumed its most formidable aspect, the danger has been attributable probably not so much to this af- fection in itself as to the cachectic habit of the patient, exhausted by previous and co-existent disease as well as by the profuseness of the dis- charge. In the majority of those instances where rhronic eczema is very obstinate, and where the most carefully adapted local treatment has proved unavailing, we should be led to suspect that there is something materially wrong with the state of the general health. We have seen such cases which had existed for years, and resisted for nearly as long a time the most judicious and energetic topical measures. In the aged it is peculiarly un- manageable, arid a cure often almost hopeless. Alibert speaks of the dartre squammeuse humide, in its aggravated form, as one of the most obsti- nate and insufferable diseases to which humanity is liable; the irritation which it keeps up, and the despondency which innumerable relapses tend to generate, having in some instances, according to him, led the unfortunate patient to the commission of suicide. Treatment.—The introduction of the sooth- ing plan of treatment constitutes the most remark- able improvement which has taken place in regard to the management of the cutaneous diseases in these latter times. In mild cases, if we can suc- ceed in subduing for a fime the irritation which exists, nature will often do the rest, and re-esta- blish the natural actions of the part. In no class of these diseases are soothing measures more called for than in the vesicular forms, in which the in- flammation is usually characterized by considera- ble acuteness and a high degree of irritation. This is peculiarly the case with some of the va- rieties of eczema. Great relief may usually be afforded by frequent ablution with tepid water or mucilaginous decoc- tions, as those of bran, marsh-mallows, poppv- heads, or of gruel or milk and water; by mild poultices, with or without the addition of goulaid, and by local and general tepid baths. Mr. Pluinbe condemns in strong terms the use of ointments, and recommends the employment of the common spirit-wash in incipient cases. Lotions containing prussic acid have been found to have much influ- ence in allaying the pruritus. When the patient is young and of a sanguineous temperament or plethoric habit, venesection should not be neglect- ed, and leeches and cupping in the vicinity of the disease are most important auxiliaries. The diet should be light and very sparing. Bateman re- commends the use of bark and serpentaria, but on no very clear indications. Mild diluents, gentle laxatives, and the use of the vegetable or mineral acids, are generally all the internal medicine ne- cessary, especially in the acuter and more rapid forms of the affection. As to the propriety of the employment of acids, so usually recommended in cutaneous disorders, we might, if guided by theory alone, have some doubts; for in certain habits, as has been remarked by Sir A. Carlisle, they of themselves occasionally excite much irritation in the skin. Thus many people are affected with pimples shortly after taking them, together with burning heat in the face and itching over the whole body. Yet here, as elsewhere, preconceived notions with regard to the propriety of a thera- peutic agent in disease, derived from a knowledge of its influence in a state of health, must not be put in competition with the practical results of experience, and we have certainly seen very trou- blesome cases of eczema yield rapidly whilst acid drinks were used. The mineral acids (sulphuric and nitric) seem, indeed, to have considerable in- fluence in the later periods in diminishing both the exudation and the itching of the affected parte; j whilst in the earliest and most inflammatory stage j those of the vegetable kind, on account of their cooling properties, perhaps deserve the preference. In the mercurial eczema, if its attack be violent, Biett, we believe, never omits the precaution of taking blood from the arm, as the best means of obviating or moderating those symptoms of irrita- tion in the mucous membranes of the respiratory and digestive organs which occasionally compli- cate it. Pearson recommends the use of diapho- retics ; but the irritable state of the stomach and bowels frequently renders them improper: and in those very rare cases where typhoid symptoms supervene, the employment of bark will often, for the same reason, be found inadmissible. Opiates have very usually been recommended by way of allaying irritation and procuring sleep, but their exhibition requires much circumspection, as opium has occasionally been known, in this as well as in the healthy state of the skin, to induce severe itching : and Dr. Moriarty met with one case in j which it apparently was the cause of a relapse. j The daily use of the tepid bath usually affords | much relief by removing the secretion and keeping | the surface pliant. Where, however, the excoria- tions are very extensive, even the tepid bath can- not well be borne, and the effort of ^citing in and out of it causes much suffering. 'J'he heat of the bath must be carefully regulated, for if of too high a temperature, it will inevitably aggravate the inflammatory tendency in the cutaneous surface. The pain caused by the rigidity and contact of the incrustations may be in some degree alleviated by the application of the linimentum calcis. Re- peated changes of the linen are indispensable, and ECZEMA. 749 will sometimes, from the abundance of the secreted matter, be necessary ils often as lliree or four tim£>s '» he course of one day. The return to mercury in tliese cases is to be avoided if possible; as even Its mildest preparations have occasionally induced a recurrence of the disease, an effect which took place in a case recorded by Dr. Crawford, from the incautious application of c-.trine ointment to the still morbid skin. In some urgent cases, how- ever, mercury has been again exhibited, and with impunity. When eczema has become chronic, the local treatment should still in almost every case be of the soothing kind. Hence a steady perseverance in the use of tepid mucilaginous decoctions, of lotions containing the acetate of lead, of local and general baths, continues, as in the first stage, to be proper. General and local bloodletting and other antiphlogistic measures will still often afford us most valuable assistance in subduing this ob- stinate affection ; the propriety of their employ- ment and repetition being of course determined by a joint consideration of the state of the consti- tution and of the local inflammation in each indi- vidual case. We cannot, however, help thinking that, in this country at least, the utility of these measures has, till within these very few years, been greatly overlooked, and that their employ- ment, even at the present moment, is quite too infrequent. This may perhaps in a great degree be attributed to their never once being alluded to by Bateman, whose bias seems to have been alto- gether towards the opposite mode of treatment, or the frequent exhibition of tonics. His preposses- sion, too, against the use of aperients in eczema is not justified by the experience of others, as they are often found to be highly beneficial. We have known very severe cases yield to the combined employment of baths, mineral acids, and laxatives. When these and the other measures detailed above disappoint us after having been fairly tried for at least three or four months, recourse may be had to the cautious use of Fowler's solution, or of tincture of cantharides. Amongst Biett's nume- rous cases under the influence of those powerful medicines, we do not recollect to have seen them ever do mischief; and hence we pirticipate fully in the sentiment with which he frequently pre- faces their prescription, namely, that no medicine, ing the mode of irritation in the part; but they are not unattended with risk, and violent exacer- bations and deep cicatrices have resulted from their employment. In the advanced scaly stage stimulant applications have sometimes been of use, by exciting a more active inflammation, and thus subverting the existing morbid action. Ointment* containing the red precipitate or tartrate of anti- mony, and blisters have occasionally been had re- course to with this view, and with success; but the practice is rather empirical, and the result du- bious. In an indolent and scaly stale, alkaline and sulphur baths may perhaps sometimes be use- ful ; but if too early employed, they are sure to aggravate the inflammation, and in the great ma- jority of cases the vapour bath is to be preferred to them. When there exists any obvious derangement of the general health, little improvement need be expected till this state be first counteracted. Country air and a careful regulation of the diet are here points of the first importance ; alterative doses of calomel or blue pill, with the decoction of sarsaparilla, will sometimes also be of great service. In those cases where there is a marked inflammatory diathesis, indicated by a full pulse, heat of skin, thirst, headach, drowsiness, &c, Dr. Elliotson has found much benefit from mercu- rial medicines, given so as slightly to affect the mouth, in conjunction with venesection and a low diet. Such a mode of employing mercury, in a disease of which it is itself an occasional cause, will, however, demand great circumspection. The use of water-dressings, in preference to all ointments and greasy applications, has long been zealously advocated by Dr. Macartney, who has directed much of his attention to the study of dis- eases of the skin. Indeed the beneficial effects which may be produced in this and several other cutaneous inflammations, merely by keeping the inflamed part constantly moist by means of lint wetted either with cold water or a weak solution of the acetate of lead, and enveloped in oiled silk, are unquestionable and striking. We do not, however, think that the employment of ointments is in all cases injurious, having known eczema of the ears and face, though attended with ex- treme irritation, receive immediate relief, and get speedily well under the use of an ointment com- however active, is dangerous in prudent hands, j posed of cold cream and the liquor plumbi acetatis Mucilaginous and diluent drinks enter largely into all his plans of treatment, and must tend materi- ally to obviate the danger of gastric irritation dur- ing the use of energetic internal medicines. Whe- ther the beneficial influence which arsenic and cantharides often display depends on their imme- diate action on the skin, or whether it is attribu- table to their effecting a species of counter-irrita- in Ihe proportion of two or three drops to the ounce, in conjunction with the repeated applica- tion of a cooling lotion, consisting of the acetate of ammonia, accurately .neutralized, largely dilu- ted, and holding a minute portion of the acetate of lead in solution. If the disease have existed about the face for a considerable time, an issue or perpetual blister to tion on the mucous membrane, and a consequent the nape of the neck or the arm effects a useful equalization of the circulation in the cutaneous I counter-irritation, and will thus often tend both and mucous surfaces, is utterly unknown. Their to accelerate the cure and to prevent a relapse. great power as modifiers of the actions of the skin j A free stale of the bowels and a frequent use of is, however, indisputable. The exhibition of frac- the bath seem also uo have much influence in tional doses of the corrosive sublimate also, given guarding against a recurrence of the affection. in a decoction of dulcamara, occasionally effects a , The propriety of a cooling and sparing diet cure where other measures have failed. j throughout every stage of the disorder, and even Caustic applications, as the nitrate of silver or for a considerable time after its disappearance, diluted muriatic acid, have sometimes been used, cannot be too strongly insisted on. as is mentioned by Rayer, with a view to chang- j W. B. Joy. 3k* 750 EDUCATION, (PHYSICAL) EDUCATION, PHYSICAL. Education, in the ordinary acceptation of the term, refers only to intellectual and moral cultivation. Mr. Locke, however, has taken a wider and juster view of the subject, and in his excellent Treatise incul- cates strenuously the attentions necessary for pre- serving and strengthening the bodily constitution. This branch has been denominated physical edu- cation. If medical science effect something more than the mere adaptation of remedies to a few spe- cial diseases; if it embrace the more enlarged and comprehensive purpose of promoting general health, and preserving the bodily frame in the full and vigorous exercise of all its functions, then is the subject of physical education entitled to a pro- minent place in every work which professes to treat of the science, or to display its most useful applications. No applications of its principles can be more useful than those which regulate the physical management of the young; for even in infancy, and still more when childhood passes on- ward to adolescence and puberty, are errors of ignorance and prejudice daily committed, which sow deeply the seeds of disease, consigning many a sufferer to an early grave, or entailing miseries which render life a burden rather than a blessing. However difficult it may be to correct the mani- fold errors by which, in early life, health and hap- piness are sacrificed, it must at least be right to point out to those who wish to learn, what are the principles by which the first of earthly bless- ings, a sound mind in a sound body, can be best insured. With bodily health, mental is here as- sociated, for the connection is intimate : if the body languishes, the mental powers, which act only through bodily organization, must fall far short of that energy and activity of which they would otherwise be capable; while the irritability of mind to which weakness and ill health are prone, is sure to act unfavourably on all the moral feelings. In the present article the design is to lay down principles rather than rules; for the lat- ter never can be so framed as to admit of univer- sal application, and when indiscriminately used, they either, through necessary variableness of effect, fail to inspire confidence and in time fall into disuse, or the good which they do accomplish is sure to be balanced by a portion also of evil. To lay down principles is the safer and better course, for though physiological truths are what few even among the most intellectual classes of society are prepared to comprehend, their educa- tion unhappily leaving them utterly unacquainted with the structure and functions of their own frames, still the dissemination of these truths, es- pecially in connection with a subject of such deep and universal interest, may not be wholly unavail- ing, but may rather prove the means of exciting enquiry, and of dispelling that ignorance to which so much of the ill health of every period of life may be distinctly traced. Man, in his relation to external objects, is sub- jected by nature to certain laws; in other words, there exist between man and the external world certain definite and immutable relations, as obliga- tory as a positive ordinance. If the relation be disregarded, the law violated, the penalty ensues with a certainty that cannot be evaded. It is well, I then, as all are subjected to these laws, arc capable I of acting in conformity with them, and sure to suffer when betrayed, whether by ignorance or wilfulness, into infringing them, that some con- sideration should be bestowed on them, in order j that errors of ignorance at least may have some chance of being avoided. The natural laws which connect man with the objects around him have been appropriately classed under three heads; namely, the physical, organic, and moral. Vitality confers no exemption from the laws of matter and motion. To these the human body is subject equally as if it were not endued with life. It is true that, while animated, it possesses to a certain extent powers capable of modifying their operation; still it never ceases to be under their influence, and it is liable to suffer whenever that influence is overlooked or miscal- culated. The body gravitates, and when deprived of support falls to the ground, equally as if it were inanimate. Physical laws, therefore, are worthy of consideration, in order that no injury may accrue from their violation. But animated bodies are subjected to laws peculiar to themselves; and as life is always connected with organization, these laws are called organic. It is with them that we are more immediately concerned on the present occasion. Man, however, is not only an organized and animated being, but also a moral and intellec- tual one; and is, in consequence, subject to further laws in relation to this part of his nature, namely, the moral. As his moral and intellectual powers, however derived essentially from his spiritual nature, are dependent on organization for their exercise and manifestation; as the several powers act interchangeably on each other ; and as a close analogy resulting from this connection subsists between the organic and moral laws, it will be necessary to take some notice of the latter in the following pages. The organic laws may be subdivided according as they regard respectively the preservation of the species and of the individual. The former of these may here be passed over as not essential to the present purpose, the preservation of the indi- vidual being that which chiefly claims attention in discussing the principles of physical education. The animal body is connected more immediately with the external world by digestion and respira- tion, it being through these processes that it derives the elements by which it subsists. Food and air are indispensable so long as life endures; and if either be withheld, or depraved in quality, or too scantily supplied, the animal languishes and prematurely dies. Other elements are most pro- bably combined ; there being reason to believe that the electric conditions of the atmosphere exert an influence on the animal economy neither slight nor unimportant. We know too little, however, on this subject to make it the ground- work of any reasoning. On the regulation of diet much of the health of the body depends. All animals are destined by nature to feedpn particular aliments, for digesting arid assimilating which they are furnished with an appropriate organization. Some are herbivorous some graminivorous, some carnivorous. Man beinz by nature omnivorous, a mixed diet of animal and vegetable food is best fitted for his adequate nutri- EDUCATION, (PHYSICAL) 751 «n !%>,- "1? ",08t accor rt a period of life when a moral feeling is sca.cely supposed to exist, and to trace its development to irritations which enlightened caution might picvent. Even at this early period the moral laws are not to be disregarded. These laws piuuounce that moial feelings no less than the physical powers acquire force by exercise, and that the surest way of weakening those which, when tending to excess, lead to evil, is to consign them as much as possi- ble to quiescence. Great care is therefore neces- sary not to arouse angry passions, and especially in infancy, when the other moral feelings, and the intellectual powers by which they are in later years controllable, are too imperfectly developed to be of avail. The principle is applicable to every period of life, and the interesting stage now under discussion should have the full benefit of it. The present occasion does not call for minute details of the management of infants, which are so familiarly known and so much under the guid- ance of competent advisers, being for the most part regulated by enlightened medical attendants, that a few general remarks may here suffice. They may be comprised under the heads of cloth- ing, food, state of bowels, air, temperature, clean- liness, exercise, moral discipline, and habits. Clothing.—The clothing of infants should be soft in texture, so as not to irritate their tender skin. It should be made so as to give free play to all the limbs, no part being subjected to con- striction or undue pressure, and should also be so ! simple as to admit of being quickly adjusted. The process of being dressed is irksome to most in- fants, causing them to cry, and exciting as much mental irritation as they are capable of feeling. It should, therefore, be rendered as brief as is com- patible with the ablutions required, and with the necessary adaptation of the garments to their several purposes. By a very little ingenuity they 1 may be so constructed as to be put on and re- I moved with little delay. It would be well if pins could be wholly dispensed with, their use being hazardous through the carelessness and stupidity of nurses, and even through the ordinary move- ments of the infant itself. Soft tapes, loops, and buttons, hooks and eyes, or other such fastenings, might be jAeficially substituted. Pood.^That the infant should derive its ear- j liest sustenance from the mother's breast was so obviously designed by nature, that the abstract propriety of mothers suckling their offspring ad- mits of no dispute. The question, however, whe- ther all mothers should discharge this duty is not thus determined, the condition of the mother and her capability of performing it requiring to be taken into account, as well as the wants of the child. When a mother is young, healthy, and sufficiently robust, it is her bounden duty, as it ought to be her dearest pleasure, to foster in her bosom the being which she has brought into ex- istence, and to nourish it with the food expressly provided by nature for its use. Every considera- tion, both physical and moral, pleads for this exer- cise of maternal function. By it the bodily health i of both mother and child is promoted, while it ex- j cites in both the purest emotions of the heart. All mothers, however, are not capable of per- forming this duty ; and, unfortunately, among the higher and middle classes of society, a considera- ble portion, through errors of phjsical education and the dehilitatin^ effects of various pernicious practices proceeding from fashion, luxury and 1 dissipation, are incapacitated for undertaking it. i Thus error perpetuates iteelf, and in ils natural EDUCATION, (PHYSICAL) 753 consequences comes to act in a circle. The dis- ] drastic purges can very rarely be needed. The sipated mother neglects her child, and this child, ' stools, if rightly understood, will furnish a sufti- W \h "r'6' commences life under disadvantages ciently certain guide. If there be evidence of which, by weakening her frame, tend to unfit her redundant and vitiated secretion, and if the removal for eventually acting as a mother. Extreme deli- j of this by purgatives relieve, pain and restore tran- cacy of constitution, diseased condition of the | quil feelings, no doubt can attach to the means by frame, defective, secretion of milk, may forbid the which these effects are obtained. But it sometimes mother to suckle her child. Unless she can per- I happens that some tinge in the fau-es, some inci- form the duty with safety to herself and benefit to ! dental pain, misleads the practitioner, inducing her infant, she ought not to attempt it. In this j him to believe that more purging is needed, when case a young and healthy wet-nurse is the best ! the prevailing distress may be owing to the irrita- substitute. But even this resource is not always tion caused by the purgatives already too freely attainable, and then it is consolatory to reflect that administered. In this case he will do well to children may be reared without material prejudice pause, and, by abstaining from interference, suffer to health, by what is termed feeding by hand, the bowels to recover the tranquillity which his though extreme care is requisite to make the sub stitution effectual. In this case the process of nature should be emulated as far as possible, and food should be imbibed by suction from a nurs- ing-bottle, rather than swallowed from a spoon. Much injury results from giving infants food too gross for their digestive powers. If nursing by hand, as it is termed, be resorted to, the food, for the early months at lea>t. should approach as nearly as possible to human milk. Milk and water, with a little sugar, is quite enough for the first two months. After which some farinaceous matter may be combined. Thick gruel, panada, biscuit- food, and such matters, are much too solid, at least in very early infancy. They overload the stomach, causing indigestion, flatulency, and grip- ing. These create a necessity for purgative medi- cines and carminatives, which again weaken diges- tion, and by the unnatural irritat.on perpetuate the evils which render them necessary. Thus many infants are kept in a continual round of repletion, indigestion, and purging, with the ad- ministration of cordials and narcotics, who, if their diet were in quantity and quality suited to their digestive powers, would need no aid from physic or physicians. The frequency with which medical aid is re- quired for infants under gastric and intestinal dis- turbance, and the numerous infantile maladies remedies serve to disturb. It is a valuable part of medical science to know when to resolve on doing nothing, and an excellent result of moral courage to dare to act on that resolution. On such occasions it is not true that medical skill is at fault or in abeyance. It only evinces the saga- city to perceive that nature is competent to her own work, and that she ought not to be interrupted in completing it. In judging of the intestinal secretions of infants, there is a source of fallacy wliich deserves lo be noticed. Mucus accumulates on the lining mem- brane of the stomach and bowels, and becomes morbid, inducing disease. The irritation of purga- tives, too freely given, will also cause an increased secretion of mucus manifested in the stools. The matters discharged, however, are very different in their nature, and can hardly deceive an experienced eye. In the former case, the mucus is opake, dense, ropy, or membranous; in the latter, it is limpid and fluid. Purgatives relieve the fonntr condition ; they exasperate the latter. Infants naturally have free bowels, and, if pro- perly fed, they need no medicine. Even in purg- ing off the meconium, art is often superfluously resorted to, or at least prematurely employed. The first milk of the mother's breast is the natural purge, and oftentimes even this is not required. A too early exhibition of castor-oil, as is very gene- which spring from this source, are sufficient proof j rally practised, is unwise. A little manna is less that their ordinary diet is not as rational as it might : irritating, and will in general suffice. Simple sup- be rendered. From errors of diet are the digestive functions of infants chiefly, if not solely, liable to be impaired, and, when these become so, correction of diet, rather than the exhibition of drugs, should be relied on for remedying the evil. We are far from inculcating that on such occasions medical advice should not be resorted to ; on the contrary, positories were formerly much in use, and perhaps they have been too much laid aside. When dis- tress, however, arises from distension or flatulency under retention of the meconium, some aperient is needed, and, for certainty of el&ct, castor-oil is perhaps most to be relied on. With respect to the general management of the bowels of infants, the our persuasion is, that, when such disturbance ' principle is that they should be kept free, and by „i;™i ,.„,..,sol is ahsohitelv necessarv. as the mildest and least irritating means. I his is arises, medical counsel is absolutely necessary, as the medical adviser is more likely to see the real nature of the evil, and adopt rational means for its correction, than they whose injudicious pro- ceedings occasioned it. But we would strenuously advise the. medical attendant to be sparing of his drugs, unless he see adequate cause for exhibiting them. We are well aware that, even in infancy, the bowels may become loaded, and their lining membrane coated with redundant mucus, and that purges, even of calomel and antimony, with rhu- barb or scammony, may be required to cleanse them, and restore healthy secretion. But such remedies should not be prescribed on every trivia) occasion, and at all events a succession of such Vol. I. — 95 irritating all that health requires. It may be finally re- marked, however, that no course of proceeding can be more prejudicial than, having first over- loaded the stomach and then administered purga- tives, followed by carminatives and narcotics, to return to the dietetic errors which created the necessity for all this discipline. Air.—It is of importance that children should breathe a pure atmosphere. During the day this is in general sufficiently attended to; but at night they are verv apt to be placed under circumstances unfavourable to a free circulation of the air around them. Apprehension of cold causes thein to be then more closely enveloped with clothing, espe- 754 EDUCATION, (PHYSICAL) cially about the head; curtains are drawn in order to exclude cold air; nay, through extreme care, a thin covering is not unfrequently thrown over the face of a sleeping infant, confining the respired air, and impeding the access of fresh air required. All these practices are bad, and ought to be avoid- ed. Tiie head should not be muffled, curtains are objectionable, and the face should not be covered during sleep. Pure air is needed, and a supply of this should be ensured without giving way to undue apprehension of cold, of which the danger is very slight, unless great imprudence be prac- tised. Infants should be guarded from cold, but much heat is prejudicial. On this as well as on several other accounts, the child should not lie in the bed with the nurse. After having sucked, it should be placed in a cradle with just so much covering as is necessary for preserving the natural temperature. Cleanliness.—Cleanliness is essential to the health of infants, the functions of the skin being of high importance, and requiring to be kept in due activity. The body should be washed all over once a day at least, and impurities should never be suffered to remain for any time in con- tact with the skin. At first the water used should be tepid, but after a few months the temperature should be gradually lowered, until cold be em- ployed, unless there be such extreme delicacy and deficient re-action as to render this hazardous. Children bear well the transient application of cold, which is in general succeeded by a genial glow, both refreshing and invigorating. Many weakly children are renovated in health and strength by means of a daily plunge in a cold bath. Exercise.—Infants, for the first month or two, sleep so much that there can be no exercise, save that of being carried about in the nurse's arms. After this time it is advisable to suffer them to exercise their limbs freely, by laying them fre- quently on a bed, sofa, or carpet, and allowing them to roll and kick at their good pleasure. The delight which this affords evinces how grateful such freedom is to their animal feelings. There is one very common mode of exercising infants, which, we think, deserves particular no- tice—we mean the practice of hoisting or raising them aloft in the air. This practice is of such venerable antiquity, and so universal, that it would be vain to impugn it The pleasure, too, which most children evince under it, seems to show that it cannot be so objectionable as a cursory observer would be disposed to consider. Still there are hazards which ought not to be wholly overlooked. The risk of accident is one of some amount: children have slipped from the hands, and sus- tained serious injury. Some people are so ener- getic as to throw up children and catch them in descending. This rashness there can be no hesi- tation in reprobating, for however confident the person may be of not missing hold, there must ever be risk of injury from the concussion suffered in the descent, and even from the firmness of grasp necessary for recovering and maintaining the hold. The motion of the body, too, has a direct tendency to induce vertigo; and when the liability of the infant brain to congestion and its consequences is considered, when the frequency of hydrocephalus in infants is borne in mind, an exercise which impels blood to the brain will not be regarded as wholly insignificant. There is one more objection which seems not to have attracte.1 attention. The hold taken of a child in the act of hoisting it is by the hand grasping the chest. The fingers and thumb placed on each side of the sternum, compress the ribs, and any one with the hand so placed will at once perceive that if the pressure were strong, and the resistance from the elasticity of the ribs weak, the impression on the chest resulting would correspond exactly with the deformity named chicken-breast. That any force is ever used capable of inducing speedily such a change is in the highest degree improba- ble ; but that reiterated pressure of this kind, how- ever slight, would in a weakly child have power to impress and distort the chest, few, we imagine, will doubt. Rocking was formerly in almost universal use with infants, though not meant precisely as exer- cise. Every cradle had its rocker, by means of which it was put in vibratory motion whenever the infant was to be set asleep. The expedient answered its purpose; but the propriety of in- ducing sleep by such means is very questionable, or rather must be utterly disallowed. Sleep here ensues because the motion promotes a congestive state of the vessels of the brain inducing a degree of vertigo. For the reasons already assigned when discussing the exercise of hoisting, this cannot be salutary, and must be scarcely safe in the delicate brains of infants. Moral Management.—To notice the moral discipline of infancy may excite a smile; and yet it is a subject of no slight moment. From the hour of birth the infant is a moral being, and sub- ject to the moral laws; and it is the duty of those, who are responsible for its culture to see that these laws he not infringed. Bodily health, too, being more or less affected by mental excitement, a treatise on physical education would be incom- plete if this source of disturbance were disregarded. Infants possess several propensities and passions of great activity ; and as neither the countervail- ing sentiments, nor the intellectual powers by which they are to be controlled in after-life, are at this age equally developed, it is the more incum- bent on those who govern them to regulate, on sound principles, the dispositions which they dis- play. Good dispositions are capable of being cul- tivated, and evil of being restrained, even in the cradle. But they who undertake the task should look well after the government of their own minds ; for if in pursuing it they yield to the im- pulse of feelings, unrestrained by the higher sen- timents and unguided by the intellect, their mea- sures will be ill adapted to the ends desired, and little likely to attain them. An irritable nurse is unfit for the care of a fretful child. The fret ful- ness may be owing partly to natural disposition ; it often arises from impaired health, or from slight sufferings occasioned by some injudicious manage- ment. Rendered uneasy by overloaded bowels, constriction from the clothing, misplaced pins or other source of disquietude, the infant has no re- source but to cry ; and if the cause of distress be not removed, habitual fretfulness and irritability of temper may become established. In a child of EDUCATION, (PHYSICAL) 755 natural good temper, when the distress is relieved, calmness returns; but if the temper be naturally irritable, this becomes aroused by the pains en- ":a"d especially if under ite sufferings the child be harshly or unkindly treated: so that even when the bodily distress ceases, equanimity is not restored. Children cry from pain ; they cry also from passion ; and no tones can be more distinct than those which express the respective feelings. The one should be promptly quieted by removing the cause of pain ; the other is less speedily cor- rigible, requiring both time and a system of sound moral discipline, to prevent habits of irritability acquiring strength by reiterated excitement. When the natural temper is irritable, causes of irritation should be carefully avoided ; the irritability should be calmly but steadily repressed ; other faculties of the. mind, too, should be called forth, as indi- rectly suspending the exercise of the irritable feel- ings ; and according as the mental powers be- come progressively developed, the higher senti- ments and intellectual faculties should be so cultivated as to ensure them that predominance of the animal economy, regularity is maintained with a precision which the dictates of reason could never command. Many of the bodily functions are signally under its influence ; and on the prin- ciple that activity gives vigour, while quiescence leads to abatement of energy, much of moral dis- cipline may be founded on the formation-of habits during those early years when the self-controlling powers of the individual are yet but imperfectly developed. In respect of food, of sleep, of the alvine discharges, a disposition to periodic recur- rence is clearly discernible ; and by attending to it, regularity of the respective functions may be sensibly promoted. Fixed periods for taking food are desirable, and they should be frequent. It is unwise to load the stomach with fresh food until the previous meal has been digested and passed onward to the intestines. From this error the gastric and intestinal irritations of infancy often- times proceed. Regular habits of evacuating the bowels, if duly established, have much effect in superseding the use of medicine. So prone are the bowels to make at certain periods efforts for over the animal propensities which the Creator their own relief, that if from any cause the periodic has allotted to them, and on the maintenance of which all virtue and happiness depend. To ex- ercise this controlling power in due time is the greatest good which the infant can experience; it lays the foundation of all moral improvement, and cannot be too early commenced. No error impulse be resisted, the effort ceases, and is not again actively renewed until the next revolving period arrives ; accumulations, productive both of inconvenience and injury, going on during the interval. It seems needless to pursue further the consideration of infancy. What has been said can be more pernicious in its consequences than* furnishes sufficient guidance for conducting the to be reckless of exciting the passions of chil dren. without considering how they are to be al- layed. Some have, been so misguided as wantonly to excite such passions in order to habituate the parties to self-control; but this error is so mis- chievous, and so irreconcilable with all sound principle, that it must be of rare occurrence. Even carelessness, however, in this respect is in- excusable ; and no child should be subjected to any irritation that can be avoided. Frequent ex- citement will, in the naturally irritable, confirm ill temper, while it will endanger the establishment of it, even in those who are naturally more calm. Irritability of temper in children should be re- garded rather in the light of a disease to be reme- died, than of a fault to be punished. They are as nature made them, and no more accountable for irritability of temper than for a weak digestion or other bodily infirmity. The possession of an irritable temper is a misfortune rather than a fault, and the being so unhappily circumstanced merits pity rather than reproof. All the assist- ordinary management of health, and for guarding against the errors to which this stage of life is exposed. So many of the principles inculcated in the foregoing inquiry apply to the next stage, or that of childhood, that this may be more briefly discussed. [See a Treatise on the Physiological and Moral Treatment of Infancy, by A. Combe, M. D., Amer. edit, by Dr. J. Bell: Philad. 1840.] Childhood.—In considering the stage of child- hood, we shall, for the sake of method, pursue the same arrangement that was followed in treating of infancy, without deeming it necessary, how- ever, to dwell more circumstantially on any point than its merits may specially require. The clothing of childhood should possess the same properties as that of infancy. It should afford due warmth, be of such materials as do not irritate the skin, and so made as to occasion no unnatural constriction. On the feeding of children their health is much dependent; and in this respect injury is often done from regulating their diet according to some ance wliich kindness and sympathy can render preconceived system founded on partial expe- should be given in support of the struggles which , rience or imperfect observation. Children, to such a being has to maintain within his own breast. Imperturbable calmness is required in the government-of children, who readily distinguish whether reproof or punishment proceed from ex- cited passion, or are resorted to solely for their correction or improvement This discussion, how- ever, must terminate here. Enough has been said to m ;rk the close connection that subsists between moral discipline and physical welfare. Tranquil support their natural growth, require ample suste- nance, and this admitted truth is with many a sufficient reason for overloading their stomachs, and with food of too nutritious a kind. Others again, from having seen healthy children reared on a low diet, and, also from having occasionally witnessed disease brought on by excess of animal food, unaware, too, of the hazard of generalising from insufficient facts, hastily conclude that low lity of mind is essential to good health, and the | diet is wholesome, and animal food prejudicial. government of the passions is important towards ' * attaining the ends of physical education. In rearing children it is necessary to bear in mind the force of habit, by which, in many parts No exclusive system can in this respect be right, nor can any precise rule of diet be possibly laid down, as this requires to be adapted in every case to the particular constitution concerned. It has 756 EDUCATION, (PHYSICAL) been already shown that a mixed diet of animal and vegetable food is that which nature has de- signed for human beings; their organization being fitted for its use. The period, too, when animal food may begin to be used seems also indicated by nature, and some portion of it seems fairly ad- missible as soon as teeth appear sufficient to mas- ticate it. These, however, are but general truths, which require continually to be modified in their application by special circumstances. The con- stitution of the child, and the effects of particular diets, will in general indicate sufficiently how it may be best sustained. If of a sound constitution, free from fever or evidences of plethora, with healthy bowels, a cool skin and clear tongue, the diet may be liberal, and some animal food may be conjoined. It is not wise to stint the growth of children by a too low diet, for, however it may for a while appear to agree, it induces a state of body deficient in vigour and unfit for maintaining full health. Children so reared are prone to scrofula, and to several other diseases marked by impaired energy of frame. Yet neither should children be pampered ; for this leads to evils no less formida- ble, though of a different character. Large meals oppress the stomach, cause indigestion, and by overloading the bowels, obstruct one of the most important excretions. Too much animal food supplies blood in excess, begetting a proneness to fever and inflammation ; and every one is aware how large a portion of the diseases of children is thus characterised. So long as the general health is unimpaired, the body and mind active, and no evidence present to mark excess of nutriment, that food may be allowed which natural appetite calls for, and which appears to yield adequate nutrition; and in such case a mixed diet of animal and vege- table food wilj be found the best for this purpose. But if languor at any time ensues, and febrile in- dications become manifested,—if the pulse become frequent, the skin hotter than natural, the tongue white and furred, the bowels irregular, — then, though these several symptoms should be only in slight degree, and unattended with any specific derangement amounting to what is considered disease, not only should the diet be lowered, and ite animal part for a time withdrawn, but measures should be taken to correct the state of repletion which has been suffered to arise. For some time after its removal, too, care should be taken to keep the diet under that which occasioned the consti- tutional disturbance. These observations apply to children of sound constitutions and robust health, and attention to them may be the means of averting much disease. In such the plethora so induced is positive; that is, the blood generated exceeds what the constitu- tion in its most healthful state could need or dis- pose of. But there is another, and a numerous class of constitutions in the management of which further principles are needed. These are by nature less robust, and, possessing less powers of resist- ing slight influences, their health becomes more or less impaired. The weakness induced disin- clines to exercise ; and thus a further source of derangement is superadded. Under these circum- stances, the nutritive matter introduced into the system, though not exceeding what the same con- stitution in a state of health and vigour would require, is redundant under its altered condition. The enfeebled powers cannot dispose of it; and hence arises a state of relative plethora, producing all the evils of the positive, while, from the partial weaknesses that co-exist, it is capable of inflicting still more injury on the frame. It is the plethora ad vires of the older writers ; and the febrile state which it induces is, like that of the positive plethora, relievable by evacuations and abstinence. But for the restoration of perfect health, some- thing more is needed than merely getting rid of the febrile excitement. Suitable treatment will abate the plethora, remove the fever, and correct the incidental derangements, so as to bring back the constitution to the point from which the oc- I currence of relative plethora had caused it to de- i viate, and increased caution in diet may prevent I the plethora recurring. But by adhering to this caution, the food required for full health may be withheld, and feebleness of habit becomes esta- blished. In this state, while it is necessary to limit the diet so long as evidences of renewed plethora are prone to occur, the necessity of im- proving the habit, so as to enable it to bear more adequate nutrition, should be borne in mind. Moderating by cautious depletion the circulation when overcharged, preserving a free state of ex- cretions, increasing the exercise, restoring tone by cold ablution or the shower-bath, with other alterations contributary to the same end, will, if judiciously applied and steadily persevered in, restore many such constitutions to a state of vigour capable of bearing the diet of full health, and exempting the parties from manifold diseases to which they would otherwise be exposed. It will be perceived that the measures here enjoined are partly remedial, partly restorative ; and it is of the first importance that the right order of their em- ployment be not reversed. If, while the remedial measures are needed, the fear of debility or other prejudice lead to the premature use of restorative means, the whole corrective process is disturbed and rendered impracticable, and disease more or less formidable is sure to result. Regulation of the bowels is one of the most important attentions by which the health of child- hood is preserved. Children of sound health, who are properly fed and have sufficient exercise, will rarely need aperient physic. Nature is fully equal to her own work, and if not obstructed will effec- tually perform it. Still the bowels of children will occasionally get deranged, and their incidental irregularities cannot be too soon rectified ; for, in- dependently of the local distress which a disor- dered state of bowels occasions, so long as this continues, a most important function of health is suspended, and part of its duties becomes trans- ferred to other organs unfitted for discharging them. Various irritations, too, resulting from nervous sympathy, ensue. To restore a healthy state of bowels whenever these become deranged, is an important part of the physical management of childhood. For this, simple means should be preferred ; but if they fail to re-establish regular evacuations with healthy secretions, more active remedies must then be resorted to, the direction of wliich belongs not to this place. Children should breathe a pure atmosphere both by day and night. By day they should be much EDUCATION, (PHYSICAL) 757 in the open air, and allowed to exercise their limbs freely, short 0f fatigue. Long walks are objectionable, and a single over-exertion of this kind is capable of doing permanent injury. In treating of exercise we wish to give one caution applicable to that period when the child first attempts to walk. Its early efferts are viewed with so much delight that they are apt to be encouraged and prolonged without regard to the mischief which they may occasion. The bones of infants have little resistance, and time is required ere those of the legs are capable of sus- taining the weight of the body. If prematurely subjected to it, they actually bend and become curved; and many an inconsiderate mother has to mourn over the deformity which she has herself created. In the upper classes of society this result perhaps is not frequent. It occurs chiefly to young mothers who have weakly children, and for obvious reasons the first child is most exposed to it. Among the poor it is very common, though their indiscretion springs from somewhat different feelings. With them it is less the indulgence of maternal emotions, gratified by the child's exhibi- tion of strength, that leads to this distortion, than the necessity of confiding very young children to the care of otheis but a few years older. This distortion, if timely noticed, is capable of correc- tion, even after sensible curvature has taken place. Much children are in general feeble; and renova- tion of strength with the regular action of the several muscles of the limb may counteract the injury sustained, and cause the deformity to dis- appear. But to produce this effect the original cause of distortion must be sedulously avoided, until firmness of bone and strength of muscle remove all hazard of perpetuating or renewing the evil. In addition to other means of establishing the necessary vigour of frame in such cases, a daily plunge in a cold bath is of signal efficacy. It is hardly necessary to enter further into the physical discipline of childhood; nor is it required in this sialic of existence to make any distinction between males and females. Happily for the lat- ter, they are, during childhood at least, strangers to those restrictions and injurious practices from which in later years they are doomed to suffer so neverely. From this period on to puberty a marked difference prevails in the management ot boys and girls, greatly to the prejudice of the lat- ter; and it is to the errors thus committed, and the calamitous evils which they inflict, that atten- tion will be chiefly directed in the following pages. Aivoi-kscknce. — Boys, though oftentimes ton much confined by the prevailing systems of school discipline, have on the whole considerable liberty. mid they avail themselves of it so as to exert freely and actively their muscular energies. By such exercise their growth is promoted, their vigour improved, their health maintained, and a robustness of frame acquired exceeding that of girls to a degree far beyond what mere difference of sex would account tor. Very different is the fate of female childhood as it passes onwards to adolescence. When this latter stage is approached, the trammels of error, prejudice, and false system begin to be imposed, restraining the free exercise of body and mind, and conforming both, not to what reason and right feelings enjoin, but to what 3o fashion and vanity dictate. The body, instead of being suffered to attain its just proportions unin- fluenced by interference of art, is to be trained into those forms which the caprice of the day admires, however unnatural, or however unbe- coming in the eye of unvitiated taste. The limbs, formed for activity, and requiring free exer- cise for the development of their structure and the maintenance of their powers, as well as for the preservation of general health, arc to be restricted to those movements to which a fancied graceful- ness attaches, even though the best powers both of body and mind wither under the blighting influence of the vicious system. The mind fares no better; for instead of the cultivation of those intellectual powers and moral feelings which con- duce to utility, happiness, and virtue, the best years of life are wasted on vain accomplishments, which, even when attained, are too dearly pur- chased, yielding but a very inadequate recompense for the time and toil bestowed on them, and which in a large proportion of instances, from being forced against nature, and without the talents that would justify such assiduous cultivation, are never acquired to the extent of answering a single good purpose, being sure to be abandoned as soon as the parties become free agents, and released from the control of their unrelenting taskmasters. Each of these subjects will require to be considered more in detail; and above all, attention must be forcibly drawn to those horrible ravages in female health that result from the visceral lesions which the tyranny of fashion occasions. To any one impressed with the reality and extent of the evils here deprecated, it is difficult to think or write on them with perfect calmness. We shall endeavour as much as possible to confine ourselves to a plain exposition of the evils deplored, and of these we shall adduce only such evidences as admit of unequivocal demonstration. Of boys it is unnecessary to say much, as the principles already inculcated apply to them equally as to infants and children. To them the advance from childhood brings but greater freedom; and if the confinement of school exceed what sound reason and the philosophy of nature would sanc- tion, they redeem the mischief by the active unre- strained gambols in which they indulge when school-hours are over. They pass much time in the open air, exercise freely, take food with appe- tite, and digest it thoroughly; whence the sto- mach and bowels are seldom disordered, and their sleep is sound and refreshing. Their clothes, too, make no injurious pressure; all their muscles are at liberty to act, and the free exercise of these promotes both their growth and activity, ensuring thus the regularity and efficiency of the several functions to which these muscles are subservient. \\ ilh girls, the ordinary modes of proceeding are much less healthful. It is not that their health is less an object of regard, or less carefully tended, but other considerations than those of health ob- tain an undue share of attention, and various practices subversive of health are pursued in igno- rance of the extensive mischiefs to which they lead. After childhood, education formally com- mences, and from this period certain objects of maternal solicitude are pursued with a zeal and earnestness which, if well directed, would be 758 EDUCATION, (PHYSICAL) worthy of all praise. As it is, that of good inten- ] tions can only be awarded; for the tendency of much that occurs at the periods of life now under consideration is to render valueless all the cares lavished, by breaking down the constitution. The first error is that of restraining the free mo- tions of the body and limbs, so natural at this pe- i riod of life, and in which the young of both sexes so much delight. The young lady is now to cul- tivate manners, to practise a certain demureness supposed to be becoming, to attend to her carriage, | keeping her head erect, and her shoulders drawn I back ; and if from inability to continue the mus- cular efforts necessary for this end, she fail to do i what nature does not empower her to accomplish, negligence or obstinacy is imputed, reproach is ■ cast, which, being felt as unjust, irritates the mo- ral feelings; and thus a slight error in physical discipline becomes a fruitful source not only of bodily injury but of moral depravation. It is a well-established fact with respect to muscular en- ergy, that the contractions of muscular fibres on which their actions depend, require intervals of relaxation ; that, if the contractions be prolonged without this relief, they in a certain time fail, so that no effort of the will can continue them. In other words, the muscles tire, and an interval of repose is necessary to fit them for renewed effort. This is familiarly instanced by the experiment of holding the arm extended, wben, even though no weight be held in the hand, the continued mus- cular action required for maintaining this position cannot be sustained for many minutes. If this be true of the firm and robust muscles of adults, how much more forcibly does the principle apply to the tender and immature muscles of early life! To preserve a good carriage, to keep the head and shoulders continually in that position which the dancing-master approves, require considerable muscular powers, such as no girl can exercise without long, painful, and injurious training, nor even by this, unless other measures to be hereafter noticed, be resorted to in aid of her direct endea- vours. We would not here be understood as un- dervaluing a good carriage, which is not only pleasing to the eye, but is, when natural, abso- lutely conducive itself to health, as resulting from that relative position of the several parts connect- ed exteriorly with the chest, which allows greatest freedom to the internal orjrans. To ensure a good carriage, the only rational way is to give the ne- cessary power, especially in the muscles chiefly concerned; and this is to be done, not by weary- ing those muscle's by continual and unrelieved exertion, but by invigorating the frame generally, and more especially by strengthening the particu- lar muscles through varied exercise alternated with due repose. Attention to general health, suitable diet, regular bowels, moderate but regular exercise, not of particular muscles only, but of the whole frame, cold bathing when needed, and other such measures, will maintain a good carriage by giving that power which the more direct means so generally practised served but to exhaust. All this may appear trivial and of slight importance, yet the principle inculcated is far from being so; and it applies to this early stage of life as forcibly as to those more advanced. Nay, more so; it is at this stage that its observance is of greatest mo- ment; for if it be here disregarded, effects may result, which, though not immediately obvious, are capable of laying the foundation of evils that cannot afterwards be redeemed. It is possible that the principle might be more clearly illustrated, more forcibly inculcated in connection with those later periods of life when the consequences of disregarding it are more prominent; but we pre- fer dwelling on it in its earliest and simplest ap- plications, as a clear conception of these will ma- terially assist in unravelling and comprehending the more complex conditions which are hereafter to be noticed. The evils produced by errors in physical education oftentimes beget actual disease, and the nature of this will ever be more intelligi- ble in proportion as we ascend to the causes which primarily induce it. It has been shown that di- rect endeavours to enforce what is called a good carriage necessarily fail of their effect, and that instead of strengthening they enfeeble the muscu- lar powers necessary for maintaining it. This fact soon becomes perceptible; weakness is no- ticed, and instead of correcting this by the only rational mode, that of invigorating the weakened muscles, mechanical aid is called in to support them, and laced waistcoats are resorted to. These undoubtedly give support,—nay, they may be so used as almost wholly to supersede the muscular efforts, with the advantage of not tiring, however long or continuously employed. Improvement of carriage is manifested, the child is sensible of re- lief from a painful exertion, the mother is pleased with the success of her management, and this success appears to superficial observation fully to confirm the judgment which superintends it In the present ignorance that prevails on all points of animal physiology, it would be quite impossi- ble to convince any mother so impressed that she was doing otherwise than ministering to her child's welfare. Yet what are the consequences to which her measures tend, and which such measures are daily and hourly producing ? It has been shown in the foregoing pages, when noticing the organic laws, that a muscle consigned to inactivity not only loses power, but becomes attenuated and wasted, its nutrition failing from want of that en- ergy which due exercise alone can confer. The fact is notorious, the principle unquestionable, although its application to the case under consid- eration has been little heeded. The muscles of the back and chest, restrained in their natural and healthful exercise by the waistcoats called in to aid them, and more signally in after-life by the tightly-laced stays or corsets, become attenuated, and still further enfeebled, until at length they are wholly dependent on the mechanical aid, be- ing quite incapable of dispensing with it for any continuance. At first, laced waistcoats are used rather for the convenience of suspending other parts of the dress than with any view of giving support to weak muscles, or of influencing the shape ; and confined to such use they would be perfectly harmless. In time, when weakness becomes inferred, not from any evidences of actual debility, but merely from the girl's not being able to maintain the unnatural and constrained posture which fashion and false taste enjoin, the advantage of compressing the chest by means of the waistcoat, so as to 4, at breakfast. t-i to 9, preparing lessons out »f school, (some of the girls permitted! to do so in the garden,) 9 to 1, al various tasks, in school. 1 to Ii, out of school, hut must not go out of doors; reading or working, and preparing for dinner. 1J to 2, at dinner. 2 to 5, in school, various tasks. 5 to5J,tea. 5J to ti, preparing to go out; dressing, or reading. or playing in school, 6 to 7, walking, generally arm-in-arm, on the high-road, many with their books in their bauds, and reading. 763 EDUCATION, (PHYSICAL) By the foregoing statements we do not mean to cast the slightest reflection on those by whom these seminaries are superintended. We have ever found them most solicitous for the health of their pupils, sedulous to preserve it, and when disease arose, unremitting in devoted attentions. But the system is faulty, and for this they are not accountable. By the influences and prejudices which uphold that system, they, like others, are chained: and until the system itself yield to increasing knowledge, juster views of the animal economy, a more correct conception of mental energies and of the injuries which their over- citement occasions both to themselves and to the bodily frame, and a firm resolution not to barter health for vain accomplishments;—in other words, until both mental and physical education undergo Two days in the week they do not walk in the even- ing at all, being kept in for dancing; but, by way of amends, they go out on two other days from 12 to 1, and then they miss writing. It i9 to be remarked that they never go out unless the weather is quite fine at the particu- lar hours allotted for walking. Th^y go to church, ail the year round, twice every Sunday, on which day no other exercise is taken. From 7 to 8, for the older girls, reading or working in school, (this is optional,) and then prayers; for the younger, play in school, and prayers. At 8, the younger go to bed. From 8 to 9, the older, reading or working, as before. 9, to bed. The twenty-four hours are, therefore, thus disposed of.— Hour.. In bed, (the older 9, the younger 10,)................9 In school, at their studies and tasks...............9 In school, or in the house, the older at optional stu- dies or work, the younger at play................ 3|* At meals......................................... 1$ Exercise in the open air .......................... 1 The above account was taken from a second or third- rate school, and applies more particularly to the season most favourable for exercise,— summer. It is to be re- marked that the confinement is generally greater in these than in schools of a higher order. That the prac- tical results of such an astounding regimen are by no means overdrawn in the preceding pages is sufficiently evinced by the following fact, a fact which we will ven- ture to say may be verified by inspection of thousands ef boarding schools in this country. We lately visited, in a large town, a boarding-school containing forty uirls; and we learnt, on close and accurate inquiry, that there was not one of the girls who had been at the school two years (and the majority had been as long) that was not more or less crooked! Our patient was in this predica- ment; and we could perceive (what all may perceive who meet that most melancholy of all processions—a boarding-school of young ladies in their walk) that all her companions were pallid, sallow, and listless. We can assert, on the same authority of personal observa- tion, and on an extensive scale, that scarcely a single eirl, i more especially of the middle classes,) that has been at a hoarding-school for two or three years, returns home with unimpaired health ; and, for the truth of Ihe assertion, we may appeal to every candid father whose daughters have hi en placed in this situation. Happily, a portion of the ill health produced at school is in many cases only temporary, and vanishes after the return from it. In ihe schools in which the vacations are frequent or long, much mischief is often warded off by the perio- dical returns to the ordinary habits of healthful life; and some happy constitutions, unquestionably, hid defiance to all the systematic efforts made to undermine them. No further proof is needed of the enormous evil produced by the present system of school discipline than the fact, well known to all medical men, that the greater propor- tion of women in the middle and upper ranks of life do not enjoy even a moderate share of health ; and persons, not of the medical profession, may have sufficient evi- dence of the truth, by comparing the relative powers «)f the young men and young women of any family in taking bodily exercise, more particularly in walking. The difference is altogether inexplicable on the ground Of sex only.—J. F. Editor. * Yuunger only two hours and a half. considerable reformation and be founded on more rational principles, the evils must exist to an extent j which no superintendent of a seminary can con- [ trol. We are sorry to be compelled by truth to ! add that we have often found the same pernicious regimen carried to as great a height, although on a smaller scale, in private families, under the eye | of a fashionable governess and a fond but injudi- cious mother. Hurried breathing, short cough, palpitation, constitute a state of indisposition ere actual disease is considered to exist. Weak back, with incipient curvature of spine, in time aggravate these devia- tions from health. Irregular bowels attend, im- pairing still further the general health, and giving rise also to special ravages of the most formidable : kind. A hard and tumid abdomen follows, the precursor and eventually the index of mesenteric derangement, which, next to phthisis, is perhaps the most intractable malady of youth with which the physician has to contend. Other evils, refera- ble to the erroneous system and to the debility occasioned by it, may also be seen. Of these, chilblains are very common, and, when they occur, add greatly to suffering and to the further decline of health. They arise from failure of circulation, and, locally considered, are analogous to frost- bitten parts; being in fact so many partial mortifi- cations resulting from loss of vitality in the capil- lary vessels. The surgical treatment which they receive is not always judicious. Regarded too much as local sores, and the irritability which they display being too much heeded, rest is enjoined, and thus even the insignificant exercise previously taken is suspended. Far better would it be, when this evidence of impaired vigour presents itself, to disregard the local ailment, and look solely to the constitutional state in which the local malady has its origin. It is a prevalent opinion with teachers and pa- rents that it is more conducive to the progress of education to keep a child at school when in infirm health, where the studies may still be continued, at least in some degree, than to interrupt them entirely by a removal to the parental roof. This is a great and often a fatal mistake. By such delay nothing is lost that can under such circumstances be accom- plished : feebleness of body is little favourable to the full exercise of mental energies. Mental faculties depend for their manifestation and exer- cise on bodily organs, and in proportion as the organs are weakened, does the vigour of the facul- ties decline. By suffering both organs and facul- ties therefore to acquire renewed vigour, powers of effective exertion are recoverable to an extent fully capable of compensating for the temporary inactivity. It is a great mistake to conceive that education advances in proportion to the time devoted to it, or to the earnestness with which it is pursued. Mental powers are capable of a cer- tain exertion only, and if they be overstrained, or too assiduously employed, they weary and decline, accomplishing much less than, with unimpaired vigour and more moderate exertion, they would be capable of doing in much less time. Dvery student is conscious of the inequality of his men- tal powers under different states of bodily health and different degrees of mental weariness, and fully sensible how little progress he makes when a EDUCATION, (PHYSICAL) 763 2;?'1S r^uiretL The ™nd, too, requires the vfri!! Trc:sc in order t0 emP,oyan and specially ifthesebe httle congenial to its prevailing taste, J^der P;l, ^ thC Iab°Ur turns to little «««int. Under the systems of education which prevail, years are wasted in pursuits which ought not to occupy a tenth part of the time, if their value were rightly estimated, and the real powers of the mind properly directed. And this leads us to consider what has hitherto been but too little attended to m conducting education, the direct influence which the exercise of the mental powers has on the bodily health. In the few following remarks on this subject we shall draw freely from an admirable paper pub- lished in the sixth volume of the Phrenological Journal, entitled «On Mental Exercise, as a Means of Health." The principles inculcated are of the highest importance, and though ema- nating in this instance from phrenological views, they have also so sure a basis in established phy- siology, that they may be beneficially applied even by those who still close their eyes to the truths of a science in which the writer of this article bus no hesitation to avow his firm belief; and which, justly estimated, has more power* of con- tributing to the welfare and happiness of mankind than any other with which we are acquainted. The importance of muscular exercise as a means of preserving and improving health is generally admitted. It ministers to the health of the body, and, as the brain has its due share of this advan- tage, mental energies are also promoted by it. " But there is great reason to believe that exercise of mind, regular active employment both of intel- lect and of moral feeling, of which the various parts of the nervous system are the organic me- dia, contributes so essentially to the well-being of the whole system, that it cannot be neglected with- out inflicting positive injury; and that, independ- ently of its mental advantages, it is necessary to the enjoyment of full physical health." It is es- sential to health that the functions of the nervous system be well performed. But the intellectual powers, with the affective and moral feelings, form a part of these functions, and so intimately con- nected are the physical and mental energies that they mutually influence each other; so that, in proportion as nervous stimulus is unduly expend- ed on the one, it becomes withdrawn from the other. Deficient or irregular exercise of nervous functions gives rise to much suffering, and in no class of beings more signally than in that to which so much of this essay has been devoted, namely, of young females of the upper and middle ranks, more especially those " of a delicate and nervous constitution, who, without any existing disease, without even having undergone any severe indis- position sufficient to debilitate the system, are nevertheless habitual invalids, and can scarcely venture beyond the limits of the drawing-room, or withdraw themselves from the rays of the sun, without some evil, real or imaginary, instantly overtaking them, and forcing them back to their retreat." Some of the sources of this extreme delicacy, and the means of remedying it, it has been the object of the foregoing pages to explain. « Yoang men of the same rank suffer infinitely less, be- cause the constantly recurring calls of business and public life operate upon them as stimuli, and, in spite of themselves, exercise the feelings and employ the intellect on objects of some perma- nent value and importance, and thus keep up a stir of life and excitement of the system which is favourable to the health of all the" functions, and to which unhappily many of the opposite sex re- main, especially in their youthful years, altogether strangers." "The three grand sources of vitality, failure or weakness of which may induce infirm health and delicacy of constitution, are the digestive, the sanguiferous, and the nervous apparatuses; and, accordingly, whenever great debility is observed to exist without any marked local disease, its true cause will almost to a certainty be found in weak- ness or deficiency affecting one or other of the three great systems of organs just named. If digestion, for instance, be radically feeble, then the chyle or nutritive material will fail, and weak- ness follow. If the lungs and circulating system be weak, the respiration will be imperfect, and the blood being inadequately acted on by air, its com- position will be impaired, and, sent in this state through the blood-vessels, it will no longer afford the usual stimulus and support to any of the or- gans, and hence again constitutional delicacy. And, lastly, if the nervous functions be defective, not only will the mind suffer, but all the functions of the body will participate with it in languor, because all of them will receive a diminished and vitiated supply of nervous stimulus, a due share of which is essential to their healthy action." The digestive, respiratory, and sanguiferous functions have been already noticed so far as the purposes of this essay require. It remains, then, only to pursue the consideration of nervous func- tions as involving and affected by the exercise of mind. So dependent is every part of the frame on the brain and nerves, that if the communica- tion between them be cut off or obstructed by dividing or compressing the nerve which conveys nervous influence, the function of the part, how- ever healthy it may be in every other respect, will cease, be diminished, or otherwise disturbed. When any organ, too, is stinted of its due share of nervous stimulus by the too great activity of some other part absorbing more than its own pro- portion, the function becomes weakened. Thus a diminution in the tone of all the other organs of the body will be experienced during an over- excitement of a few in writing or thinking intently, processes during which the vital actions and nei- vous energy are so much concentrated in the head, that from pure want of it the extremities become cold, and the action of the heart is lowered so as to weaken and retard the pulse, thus showing that a weak and inactive nervous system must exert an unfavourable influence on the general health. For guidance in strengthening and developing the nervous system so as to render it fit for the adequate performance of all its functions, we must look to the general principles of phy.siology and the dictates of experience. " When any living part is called into frequent and regular exercise, 764 EDUCATION, (PHYSICAL) especially if the system is not yet arrived at full maturity, it is observed to become gradually more and more susceptible of action ; to increase in size within certain limits determined, bv the con- stitution; and thereby to gain strength, as indi- cated by an increased power of enduring fatigue, and a greater capacity of withstanding the influ- ences of 1 lie common causes of disease to which previously it would have yielded almost immedi- ately. The physiological explanation of this, as proved by experiments, is, that exercise causes an increased action in the nerves and blood-vessels of the part, by which its vitality is augmented, and a greater supply of blood and nervous stimulus sent to it to sustain and repair the greater waste that is taking place, and also to supply additional sub- stance to fit it for the unusual demands made on it. The results of this process are visibly exem- plified in men whose habits or profession lead them to constant muscular exertion ; in sports- men, for instance, in blacksmiths, dancers, porters, &c.; and if it is less manifest in other parts of the body besides the muscles, it is only from other tissues admitting of less expansion, and showing their increased power in a different way. The improvement of the memory is a familiar instance of an increase of mental power produced by exer- cise ; and the beating sense of fulness and quick- ened circulation in the head induced by intense study or thought, shows that an organic process goes on when the brain is in activity, simil.ir to that which takes place in the muscular system under exercise." On the contrary, when the organ is little used, little expenditure of its power and substance takes place, little blood and little nervous energy are required for its support, and therefore little is sent; nutrition in consequence soon becomes languid, and strength impaired. To all these laws the brain is subject equally as the rest of the body. Frequent and regul.ir exercise gives it susceptibility of action, with power to sus- tain it, the nervous energy acquiring strength as well as the vascular. Disuse of its functions, or, in other words, inactivity of intellect and of feel- ing, impairs its structure, and weakens the several powers which it serve-; to manifest. The brain, therefore, in order to maintain its healthy state, requires to be duly exercised; and as it consists of several parts, each performing its proper func- tion, and ns what holds good with respect to the whole collectively, is equally true of each part individually, it follows that for healthful and adequate exercise every function requires its due share of employment, else not only do the portions consigned to inactivity become impaired, but the general health becomes deranged by the irregular distribution of nervous stimulus thus occasioned. But such is the nature of the mental functions, that each must he excited by its proper stimulus, or both it and the portion of brain subservient to it are consigned to inactivity and consequent loss of power. No one v,,>uld think of exercising the eye by sound, or the ear by colours. The effect of mere quiescence arising from the want of appro- priate stimulus is signally manifested in the case of persons, and especially of the young, who in one situation manifest certain faculties very feebly, but who, when removed to another in wliich appropriate and adequate stimulus is supplied, evince powers such as they were never previously supposed to possess. When we consider how few of all tho faculties which the mind possesses are duly exercised in the courses of education, both for males and females, which prescription, preju- dice, and fashion have ordained, we can have little difficulty in comprehending how nervous derangements of various kinds result from causes so efficient in producing them. "An appropriate example may be found in the case of a nervous young lady, whose education has communicated nothing but accomplishments, who has no mate- rials of thought, and no regular and imperative occupations to interest her and demand attention: who takes no active part in promoting the welfare and comfort of those about her; who looks to others for support and sustenance; and whose brain is in fact half asleep. Such a person has literally nothing on which to expend half the nervous energy which nature has bestowed on her for better purposes. She has nothing to excite and exercise the brain, nothing to elicit activity; her own feelings and personal relations necessarily constitute the grand objects of her contempla- tions ; these are brooded over until the mental energies become impaired ; false ideas of existence and of providence spring up in the mind ; the fancy is haunted by false impressions; and every trifle which relates to self is exaggerated into an object of immense importance. The brain, having literally nothing on which to exercise itself, be- comes weak, and the mental manifestations are enfeebled in proportion ; so that a person of good endowments, thus treated, will often exhibit some- thing of the imbecility of a fool. But suddenly change the circumstances in which such a person is placed ; suppose, for example, that her parents lose their health or fortune, and that she is called on to use her utmost energies in their and her own behalf; that in short her brain and mental facul- ties, her intellect and her moral and social feelings, are blessed with a stimulus to act ; the weakness, the tremors, the apprehensions which formerly seemed an inborn part of herself, disappear as if by enchantment; and health, vigour, and happi- ness take place, solely because now God's law in fulfilled, and the brain with which he has con- nected the mind is supplied with that healthful stimulus and exercise which he ordained to be indispensable to our comfort and welfare." We once attended a young lady for various nervous complaints, who possessed the most exqui- site sensibility of frame we ever witnessed. For years she had endured almo.st every form of the most aggravated hysteria. She was brought up with every refinement of education, and the habitual indulgence of every luxury, her parents appearing to live only for the purpose of minister- ing to her gratifications. Such was her acuteness of sensibility that at certain times the mere open- ing or closing of a door was agony ; such her helplessness, that oftentimes she could scarcely muster energy enough to raise her hand to her head. In the midst of this her father became bankrupt, and soon after died. His family were now obliged to labour for their support, and on this feeble creature devolved much of the care of providing them subsistence. She hail talents, and hhc exerted them. With the assistance of friends EDUCATION, unlT,?Ctl & 8ch001'Which she ««P«rintended with vannT T" ,Ti,iuity- Hcr ,,ervOUS m^ies Zr !u ?"? l0r yeafS She P««evered steadily in her altered but more happy course of life. It would have been fortunate if she had commenced this earlier; for the delicacy of constitution created by early mismanagement laid the founda- tion of phthisis, of which she eventually became a victim. While inactivity 0f brain leads to evil, over- excitement is no less injurious; and if persisted m without suitable relaxation, exhaustion and permanent weakness are the results. In ordinary education both errors are committed. The mental powers exercised are too few, and these are con- tinually overworked, while the larger portion is left to chance for obtaining any exercise at all. In education, too, attention is too exclusively directed'to the intellectual powers, while the effective and moral faculties are unheeded, or only acted on through the intellect. And yet they admit of rational culture equally as the intellectual powers, while on them and on their government do the virtue and happiness of mankind far more depend. Intellect is no doubt capable of assisting in this government, but never can the moral feel- ings be disciplined through intellect alone. Ethical discourses, the most eloquent and conclusive, may be pronounced, but alone they reach not the heart. The moral sentiments, to be truly cultivated, must be felt; objects must be presented capable of ex- citing emotions; and then intellect may interpose to assign the just limits of theii indulgence. No discourse ou charity can have the effect of a real opportunity for doing a benevolent action. No lecture on justice can make impression equally as an occasion of exercising this quality, especially where other incitements opposed to it require to be overcome. A conquest thus gained does more to confirm the principles, from the deeper impres- sion made by a practical example beyond that of a speculative rule, and fiom conscious satisfaction and heartfelt pleasure derived from every victory over self, when once the victoiy is completed, than all that the most profound moralists ever wrote. The minds of the young should be exer- cised in all the faculties by wliich their social condition in after-life is to be maintained, and in this some attention should be given to the natural order of their development; for some precede others in activity, and also become more quickly matured. Most of the affections and moral senti- ments may be observed in their manifestations even in the cradle. Of the intellectual powers, those which are employed in acquiring a know- ledge of the external world are earliest developed. The reflective faculties advance more slowly, and hardly attain full power until the body reaches its full growth. Much of our ordinary courses of education is in opposition to these facts. Many of our classical books which mere boys are con- demned to read, require not only mature intellect, but considerable knowledge of the world for their comprehension. The object of education is to fit human beings for maintaining their social relations, and perform- ing all tlieir several duties in life. For this end they should learn the properties of bodies, and also the qualities by which men act on these and (PHYSICAL) 766 on each other. Minute and intimate knowledge of all these it would be impracticable for any indi- vidual to attain, nor is it necessary; but an outline of them is within the reach of all, and this, which to any ordinary capacity would be only pleasura- ble acquirement, may prove of much practical utility, while by exercising the cerebral organs it will invigorate both these and their functions, be a source of much pure gratification, withdrawing the mind from selfish and sensual pursuits, and through its manifold influences have a beneficial effect on the general health. The various branches of natural science are among the best exercises on which the young mind can be employed; for while they engage a large number both of the knowing and reflecting faculties, they incite also several of the higher sentiments by presenting to the mind the wisdom and goodness of the great Creator, so abundantly displayed in all his works ; the benevolent purposes for which all these are designed, the good which they impart, and the happiness which they diffuse. Such contempla- tions withdraw the mind from selfish passions, consigning them to that quiescence which lightens the task of keeping them under due control. Above all other studies, however, that of the mind itself is the most interesting and the most important. By it alone can we form a just estimate either of ourselves or others, or have any clear conception of the powers with which nature has endowed us. Some knowledge of these powers must be of material assistance to us in regulating their exercise, ascertaining their objects, and re- straining their excesses. The subject, however, is far too copious for this place, and unsuited for the present occasion. What has been adduced was necessary in order to convey any conception of the influence of mental actions on the bodily frame, and to show the intimate connection that subsists between mental and physical education. That the foregoing sketch of the latter is far from complete we are well aware. Many points of de- tail have been passed over or slightly noticed, which would admit of more copious illustration and more explicit instruction. If we mistake not, however, enough has been advanced to display the principles on which physical education should be conducted; and an outline at least has been furnished which each reader may readily fill up according to his intelligence, and to the condition of life to which it is to be applied. E. Barlow. ELECTRICITY.—When a substance has acquired the power of first attracting and then re- pelling light bodies placed in ite vicinity, and of emitting sparks, it is, in the language of electri- cians, said to be excited. These phenomena, we are told, were first observed by Thales of Miletus in a piece of amber, which by the Greeks was called rjXtKTpov, and hence the origin of the term electricity. Electricity may be developed by several means, the chief of which are friction, the contact of dis- similar substances, pressure, variations of tempe- rature, and chemical action. In the present article we shall confine ourselves to the first-mentioned source, and shall dwell even upon it no further than may be necessary for rendering intelligible 766 ELECTRICITY. what we shall have to say respecting the thera- peutic applications of the electric fluid. When a glass rod is rubbed with silk, and then brought close to a little sphere of elder pith sus- pended by a silk thread, a combination commonly called an electric pendulum, the sphere is first at- tracted by the glass, and, upon contact, immedi- ately repelled. But upon substituting for the glass rod one of metal, no such phenomena will be ob- served. Such experiments have suggested a divi- sion of bodies into two classes, the electrics and the non-electrics, or those which admit and those which do not admit of being rendered electric by friction. Glass, sulphur, wool, silk, and all resi- nous substances are electrics. Carbon, the several metals, water, and every variety of organized sub- stance, in consequence of the water which all such include, acid and saline solutions, &c. are non-electrics. This division, however, we shall presently find to be based upon an erroneous sup- position. All bodies, in fact, are electrics ; and if there are some which, under ordinary circum- stances, do not appear to become excited by fric- tion, it is because the electricity is permitted to flow from them into the earth as fast as it is gene- rated. This brings us to another division of bodies, having reference to their electrical relations, found- ed on a different principle, namely, that which re- solves them into conductors and non-conductors, or rather into those which are with facility and those which are with difficulty traversed by the electric fluid; for, strictly speaking, there is no absolute non-conductor. If a glass rod be applied to an excited body, it will become electrified merely at the point of contact. But if a metallic rod, suspended upon silk, be applied in a similar man- ner, it will at the same instant exhibit symptoms of excitement at every point. This simple expe- riment illustrates sufficiently the difference of the conducting powers of the two rods. When a body is surrounded on every side by non-conductors, it is said to be insulated. Thus a ball of metal resting upon a cake of resin, or a stool with glass legs, or suspended by a silk thread, is insulated, for it is in connection with the earth only through the medium of non-conductors. If the insulation were perfect, the ball once electri- fied should continue so for an indefinite time. In practice, however, this never occurs, for the reason already assigned, namely, that there are no abso- lute non-conductors. Dry air is probably the best insulator with which we are acquainted ; but, by- impregnation with aqueous vapours, it acquires conducting powers. The two divisions just noticed admit of being reduced into one, the electrics being non-conduc° tors, and the non-electrics conductors. It is, in fact, owing to this latter coincidence that some bodies appear incapable of being excited. Thus, if a disc of copper, held in the hand, be rubbed with a silk handkerchief, it does not become ex- cited ; but if, before the application of the friction, it be insulated, the usual phenomena manifested by electrics will present themselves. In every case of electrical excitement two dis- tinct powers are coteinporaneously developed. Thus, when glass is rubbed by silk, both become electrified, as may be proven by approaching them j in succession to an electric pendulum. The elec- tricity of the glass, however, is different from that of the silk, for when either is communicated to two contiguous pendulums, these repel each other. But when the electricity of the glass is communi- cated to one pendulum, and that of the silk to the other, attraction ensues. These different powers require to be designated by different names, and hence the terms vitreous and resinous, which, whatever be the substances rubbed, are applied to the distinct energies developed by the process of friction. Such was the language of Dufay. But, in more modern times, these designations have been by some replaced, particularly in Great Bri- tain, by the terms positive and negative, intro- duced by Franklin, the former corresponding to the vitreous, the latter to the resinous electricity of Dufay. This difference of nomenclature de- pends upon the different opinions entertained by these philosophers respecting the nature of the electric influence. Dufay viewed it as a com- pound, Franklin as a simple fluid. The former referred all electrical phenomena to the resolution of the compound into its vitreous and resinous elements. The latter explained them by supposing that all bodies, in their natural or neutral "state, contain a certain quantity of the electric fluid, and that the processes, which produce electrical ex- citement, operate merely by disturbing this pro- portion, and thus causing an accumulation in some and a deficiency in others. We shall not enter here into any criticism upon the respective merits of these rival hypotheses. Suffice it to say, that the theory of Dufay is that adopted by the highest authorities in science, principally, as it would seem, because of its analogy to that which is alone applicable to the kindred subject of mag- netism. In order to a consistent explanation of all known electrical facts, it is only necessary to sup- pose, with Dufay, that electricities of the same name repel, and of contrary names attract each other, and with a force varying in the inverse ratio of the square of the distance. This principle of the action of the elementary fluids at a distance is applicable to a multitude of phenomena, amongst others, for example, to the charging of the Ley- den phial. By electricians it is known under the name of induction or influence. It may be illus- trated by the attraction already noticed as occur- ring when we approach an excited glass tube to an electric pendulum. The vitreous electricity of the tube decomposes the natural fluid of the'ball of the pendulum, attracting its resinous and re- pelling its vitreous element; the attraction, how- ever, being more energetic than the repulsion, in- asmuch as it is exerted at a shorter distance. But, as the ball is insulated, its constituent electricities are merely separated from each other, hut cannot leave it; hence it will itself be carried towards the tube, and with a momentum corresponding to the difference of the opposed forces. There is but one point more connected with the theory of electricity to which it is necessary to advert here. When a body is electrically charged, the free electric fluid is confined -solely to its sur- face, and does not. as experiment proves, dip to any appreciable depth into its substance. Its dis- tribution, however, on the surface is never equable ELECTRICITY. 767 cept i„ one case, namely, when the body is a spnere In all other MMa u accurnulateg in greatest quantity upon the most prominent or Projecting points. But the tendency of the elec- tric coating of an excited body to escape, is, as l.aplaee has shown, proportional to the square of its thickness. Hence we deduce the practical inference that a body studded with points cannot be strongly charged, for before much free fluid has been communicated to it, such a quantity will have accumulated at the points as to flow out in a continued stream, by forcing a passage through the atmosphere. Having disposed, in this short summary, of the principles of electricity, we shall now briefly de- scribe such articles of electrical apparatus as are indispensable with a view to its application as a medicinal agent. These are the machine, the insulating stool, the director, the Leyden jar, and the discharging electrometer. The electrical machine is the piece of apparatus employed for the purpose of obtaining electricity in considerable quantity. It consists essentially of three parts; the rubber, the substance rubbed, and the conductor or conductors, for there are sometimes two of them. The substance rubbed is invariably of glass, and is sometimes a flat disc, but more usually a cylinder. By a winch handle, attached to one extremity of its axis, a motion of rotation is given it, and it is thus made to slide upon the rubber, which is nothing but a leathern cushion, to which a small quantity of an amalgam (composed of one part of tin, two parts of zinc, and six parts of mercury) is usually applied, and to which is appended a flap of silk, which embraces the semi-circumference of the cylinder, or, in the case of the plate, in which there are two cushions, extends from an extremity of the vertical to one of the ends of the horizontal diameter. The fric- tion exerted between the glass and the rubber effects a continued decomposition of the electric fluid residing on their common surface, the vitreous or positive element being determined to the glass, and the resinous or negative element to the cushion. The latter passes at once to the nega- tive conductor which is in contact with the rub- ber,* and from it, if uninsulated, into the earth. The former developes, by the process of induction, electricity of the same name in the positive con- ductor, which is an insulated metallic cylinder, or system of cylinders, straight or curved, presenting to the glass a number of points, which are placed at a distance from it not exceeding a quarter of an inch. When positive electricity is required, the negative conductor must be uninsulated, by hanging upon it a metallic chain so that it may reach the ground. On the other hand, when negative electricity is required, the negative con- ductor is insulated, and the positive one put in connection with the earth. In order that the machine may work well, it is necessary that it be rendered perfectly clean and dry, by placing it before the fire, and rubbing it carefully with silk or flannel. Especial care must be taken that the conductor of which the electricity is wanted be well insulated, and this is best ensured by gently * In the plate-machine there is no negative conductor, the cushions being, through the wooden frume, in con- nection with the earth. heating its glass leg; for the deposition of hygro- metric moisture upon it is thus rendered impossi- ble. The nature of the insulating stool is announced by its name. The back may be of any material, but the legs are invariably of glass, this being the strongest of all non-conducting substances. The director is a brass rod of about a foot in length, terminating at one end in a ball of the same metal, and at the other in a glass handle. The ball admits of being sciewed oft", and, when removed, exposes to view the extremity of the director ending in a fine needle-point. This point should also screw off, for the purpose of being occasionally replaced by one composed of baked wood, or of brass covered with lac varnish. The Leyden jar is a cylindric glass vessel, coated within and without to about two-thirds of its height with tin-foil, and closed above by a wooden plug perforated by a brass wire, which terminates outside in a ball or knob, and inside in a chain prolonged so as to reach the inner coating. To charge the jar, its knob is made, to touch on« of the conductors of the machine while in action, its outer coating being, at the same time, uninsu- lated by being held in the hand, or in any other way put in connection with the earth through conducting substances. The inner coating ob- viously acquires the electricity of the conductor which it touches, while the outer surface becomes, at the same time, charged with the opposite fluid in virtue of the principle of influence. To dis- charge the jar, the two surfaces are to be con- nected by some good conductor. Thus, upon applying one end of a metallic wire to the outer coating, and approaching the other to the ball or knob, the opposite electricities rush together, pre- senting the phenomena of the spark, — that is, a flash of light accompanied by a sharp snapping sound, and both surfaces return to the natural state. Of the discharging electrometer there are many modifications. It is, however, essentially nothing but a brass rod terminated by balls, and supported in the horizontal position by a glass leg. If, while a jar is charging, one end of the rod is placed within one-eighth of an inch of its knob, the other extremity being connected, through some con- ductor, with the outer coating, a very slight charge will cause the spark to pass between them. If the distance be now increased to a quarter of an inch, a stronger charge must be communicated to the phial before its spontaneous discharge will take place, and so on, so that, by properly adjusting the distance, we can regulate the maximum charge at pleasure. When a spark is taken by approaching the knuckle to a machine in action, it causes a pecu- liar pungent sensation, the nature of which it is not easy to convey by description. Generally speaking, however, when thus produced, it is not, unless the machine be very powerful, accompanied by much pain. But if a loaded jar be discharged through the body, which may be readily done by applying one hand to the external coating and the other to the knob, a sensation of an exceedingly distressing kind will be experienced, which is usually and very appropriately denominated the shock. The distance to which the shock extends 768 ELECTRICITY. depends upon the magnitude of the coated surface und upon the intensity of its electricity. Thus, with a certain charge, it is felt St the wrists, with a stronger at the elbows, and with a still stronger, even at the chest. A surface of thirty square inches, when lo.ided by a common machine, is capable of destroying mice and small birds, and there are few individuals of the human species who can receive with impunity the maximum charge of a square foot, or one hundred and forty- four square inches. It is worthy of remark that the bodies of animals destroyed by the electric shock are very prone to putrefaction, that the irri- tability of the muscular system seems almost en- tirely destroyed, and that their blood does not coagulate. Similar observations have been made upon animals struck by lightning. The influence of the shock seems particularly directed to the nervous system. A small charge passed through the head of a bird deprives it of sight, and a considerable one received in the head by Mr. Singer had the effect of a violent blow, and was followed by a temporary loss of memory. When a jar is discharged along the spine of a person in the erect position, the action of the muscles is for a moment suspended, and he falls to the ground. Electricity, therefore, produces a paralysing effect when brought to bear upon the centre of the nervous system. But when trans- mitted to the muscles of a limb, the invariable consequence is their spasmodic contraction, and this is true even though the member be in a para- lytic state. Some recent researches, which will be noticed under the head of Galvanism, render it highly probable that the muscles are not directly sensible to the stimulus of electricify, but that they are thrown into convulsive action by the electric fluid, merely because of its traversing the nerves by which they are supplied. Electricity was very early employed as a thera- peutic agent, and is even still resorted to by phy- sicians, though it has lost much of the celebrity which it once enjoyed. The diseases in which it is applied are the different forms of paralysis, in- cluding amaurosis and deafness when functional affections, epilepsy, hysteria, chorea, chronic rheu- matism, particularly those forms of it which pro- duce stiffness of the joints, cases of retention or suppression of the menstrual flux, nervous head- achs, and local pains unconnected with inflamma- tion, asphyxia produced by drowning or the irre- spirable gases, enlargements and obstructions of the glandular system. These are the affections for which it is still prescribed, and occasionally with success. But there is scarcely a disease in nosology for which it has not at one time or an- other been recommended. As a remedial agent, electricity may be applied in five different ways. The first method, which is, we believe, at present employed, is to excite the patient by placing him upon an insulating stool, and putting him in connection with the prime conductor of a machine in action. This is what is called the electric bat... It was strongly recommended by Priestley, at ,ureiitly under the impression adopted irom the Abb.; Nollet, that the animal functions are, under such circum- stances, discharged with increased vigour, particu- larly the circulation ol the blood and the cutaneous. secretion. Such effects are sometimes observed, but by no means invariably. The bath was em- ployed by Lit and De Haen, two early writers upon medical electricity, for the treatment of hysteria. The next and simplest method of applying electricity to the cure of disease is to present the member, or part affected, to the prime conductor of the machine, and thus cause it to receive a succession of sparks; or, what is more convenient, to plnce the patient on a chair, and convey to him the sparks by means of a director connected with the conductor by a chain. The patient may manage the director while the operator works the machine. The third mode consists in placing the patient upon an insulating stool, putting him in con- nexion, through means of a chain or metallic rod, with the prime conductor, and drawing sparks from the seat of disease or pain by simply pre- senting to such part the knuckle, or, should the operator dislike receiving the spark himself, an uninsulated director. This method of operating has the advantage over the preceding that it con- joins the electrical bath with the influence of the spark. It is, therefore, that usually adopted by those experienced in the medicinal administration of electricity. The force of the spark is propor- tionate to its length, so that, by properly dimi- nishing this, its strength may be reduced to any required standard. A favourite mode with some practitioners of ap- plying sparks is to give or draw them across flan- nel. For this purpose, a director, terminated by a large ball, which is to be covered with a fold of flannel, is approached in the usual way to the or- gan to be electrified. Instead of a single strong spark, a series of weak ones will thus be produced, which, emanating at the same instant from several of the woollen fibres, extend over a considerable surface and produce in it a peculiar pricking sen- sation. The ball of the director may be naked, the flannel being laid on the part of the body which is to be submitted to the influence of the sparks. This method is supposed to be particu- larly suited to the treatment of rheumatism and paralysis, especially in patients who cannot en- dure the stronger forms of electricity. The next form of medical electricity to be no- ticed is the aura, or jet of air, which proceeds from an electrified point. This is the modifica- tion of the electric influence to which ulcers, ex- coriated surfaces, and delicate organs, such as the eye and testicle, are usually subjected. The com- mon method of employing the aura is to present a pointed director, connected by a chain with the conductor of the machine, and held by a glass handle, to the part affected. The particles of air in contact with the point are highly electrified, and, of course, immediately repelled. The same occurs to those which take their place, and so on in succession, producing a current of highly ex- cited air, which, as has been just described, is di- rected upon the organ which is the subject of electrical treatment. The aura may also be ap- plied by placing the patient upon an insulating -tool, and directing an uninsulated pointed di- rector to the seat of disease. It is, however, sel- dom resorted to, as its etiicacy is more than ques- tionable,. ELECTRICITY. 769 i* ^k*? ! po,nt which terminates the director is o baked wood, this being a bad conductor, the electricity does not issue in a continuous stream, out as a succession of minute sparks, which pro- duce in the part of the body upon which they are directed a sensation perfectly similar to that which attends electrization across flannel. This kind of electricity is applicable to cases where the aura is not sufficiently energetic, and where the sparks proceeding from a ball are found too pungent. tor the. application of electricity to deep-seated parts, such as the exterior of the mouth or the bottom of the external meatus of the ear, a partic- ular form of director has been devised, the descrip- tion of which may with propriety be given here. A glass tube of about one-tenth of an inch inter- nal diameter is left open at one end, and is closed at the other by a cork, through which there slides a brass wire, terminated within by a ball, which, as in the common director, screws over a point. To apply this instrument, the open end of the tube is introduced, we shall suppose, into the ear, and the external extremity of the wire being brought as close to it as may be deemed advisable, sparks, or the aura, are communicated or drawn in lbje usual way. The glass tube, being a non- conductor, prevents any lateral divergence of the electric fluid, and directs it upon the point placed immediately beneath its orifice. When shocks are deemed necessary, we must have recourse to the Leyden jar, and this consti- tutes the fifth form under which electricity may be exhibited medicinally. The method, of course, consists in discharging a loaded jar through the affected part or member as often as may be con- sidered advisable. The readiest method of ac- complishing this is to place the free extremity of a copper wire, wound about the outer coating of a charged phial, in contact with one end of the course which it is intended to make the electrici- ty traverse, and then bring the knob of the jar to the other end. When the knob comes within the striking distance of the body, the discharge takes place, and the shock is felt in the interval which separates the knob and wire. Against this me- thod, however, the objection lies that we arc not enabled to measure the amount of the charge, and that the shock, therefore, does not admit of being graduated according to the feelings of the patient, or the nature of the disease. To attain this ob- ject, it is necessary to interpose the discharging electrometer, already described, in the arc which connecU the outer and the inner coatings of the phial. The knob of the jar being now placed in contact with the conductor of a machine in rota- tion, and at the selected distance from one of the balls of the electrometer, the discharge takes place as soon as the free electricities have acquired suf- ficient tension to force their passage through this interval, and a shock is felt in the part of the body which compleies the circuit. If this be too strong, the ball of the electrometer must be placed ut a less di-tance from the knob ; if too weak, the distance between them must be augmented. The two parts of the body between which it is in- tended that the electricity shall pass are to be touched by the balls of two separate directors, held by an assistant, and connected, by means of Vol. I___97 3* chains, the one with the electrometer and the other with the outer surface of the jar. Thus, if one of the directors be in contact with the hip, and the other with the knee, when the discharge takes place, the shock will be felt along the entire thigh. This method of regulating the 6hoek should be familiar to such as employ electricity in the prac- tice of medicine. The discharge of a small jar proves fatal, as we have seen, to the smaller ani- mals; and there can be no doubt but lhat by means of a battery of no very great surface human life might be destroyed. The power, too, of sus- taining the shock is very different in different in- dividuals, and even varies in the same person so as to differ at different times, and in different states of the system. These circumstances enjoin caution in the administration of electricity, par- ticularly by means of the jar; and it may be added that, in point of fact, its injudicious and indis- criminate use has proved extremely injurious. To this effect may be quoted the case of a young girl labouring under paralysis of the right arm, related by Dr. Harte, (Phil. Trans, vol. iii.) who, after two shocks, became universally paralytic. From this state she was with difficulty recovered by judicious medical treatment, but relapsed upon being again subjected to three discharges of the Leyden jar. Alter the lapse of four months she was again relieved of the maladies inflicted upon her by electricity, and, nothing discouraged by his first failures, the doctor, it is said, would have re- sorted to the shock a third time, but Priestly quaintly observes, "the girl being more nearly concerned in the experiment than her physician, thought proper to decline it." The medical read- er who resides in the vicinity of an electrizing quack will, no doubt, be able to call to mind simi- lar cases. In the employment of electricity as a curative agent, there are certain precepts to be borne in j mind, without an attention to which disappoint- j ment will be often experienced, and unmerited discredit thrown upon a really efficacious means , of subjugating morbid action. These may be reduced to the following heads. 1. Electricity should be only considered as auxiliary to other modes of medical treatment ! which experience has shown to be advantageous. Thus, in rheumatism, it may be combined with I diaphoretics; in chorea, with tonics; and in pa- ralysis, with medicines which, like strychnia, stim- ulate the nervous system, a practice recently adopt- ed for the cure of palsy arising from the absorp- ' tron of lead. 2. We should always commence with its weak- ! er forms, such as the bath of aura, next proceed j to sparks, and finally, should these prove insuffi- cient, to shocks, taking care to regulate their j strength by the means already described, and I avoiding their exhibition, when of such degrees I of energy as to prove distressing to the feelings of the patient. The sparks applied in amaurosis, I or for the discussion of glandular tumours, must j be feeble, and in such cases shocks are quite inad- missible. To communicate the latter, a jar, four inches in diameter and six iu height, will be found amply sufficient, and its knob need never be placed at a greater distance from the ball of the electro- HO ELECTRICITY —ELEPHANTIASIS. meter than one-fourth of an inch. An interval of from one to two-tenths of an inch will, gene- rally speaking, be sufficient. 3. The electrization should be performed daily, and be persevered in for at least a month, if ne- ossary, and a cure must not be despaired of be- cause there is no immediate relief experienced ; for the go. >d effects of electricity generally require a long time for being developed. 4. The aura may be applied for from five to ten minutes. The number of shocks passed in one direction should not exceed twelve, nor the number of sparks applied to the same part twenty- four. 5. In local affections, the electric fluid should be confined to the diseased part or organ. But in diseases, such as chorea and epilepsy, in which the entire system seems to be engaged, it must be applied generally over the body. Such parts, however, as are affected with pain, or any unusual sensation, should be particularly dwelt upon. The modus operandi of electricity, in the cure of disease, is considered obscure. It would ap- pear, however, in its ordinary forms to act as a simple stimulant. Upon the nervous system, in- deed, it is by many supposed to exercise a partic- ular influence, of the nature of which we shall be enabled to form some idea, should the hypothe- sis broached in modern times, and which refers the functions of the nerves to currents of electri- city transmitted through them from the brain and spinal chord, turn out to be correct. We shall revert to this subject in the article Galvanism, and shall here merely remark that, assuming the theory alluded to to be sound, it will be proper, in the medicinal administration of electricity, to cause the positive fluid to pass through the body always in the direction of the ramification of the nerves. This precept is particularly insisted upon by some foreign electricians. The spark received from substances resinously electrified differs, in some respects, from that which issues from surfaces vitreously charged. It is more pungent, and has a different shape, being shorter, and not so regular in form. As medicinal agents, however, they appear both to produce similar effects. A contrary opinion has indeed been maintained by some, who have represented resi- nous electricity as a sedative, and vitreous as a stimulant. This theory, which is quite unsupport- ed by facts, is not a modern invention. It origin- ated in 1779, with Bertholon of Montpellier, who resolved diseases into two classes, those which de- pended on an excess, and those which were the consequence of a deficiency of the electric fluid, and treated the former with resinous, the latter with vitreous electricity. It is not necessary to enter upon any formal refutation of such an ab- surd hypothesis. In it, however, may be recog- nised the germ of the more celebrated but equally unfounded nosological notions put forward two years after by Dr. John Brown, in his « Elementa Medicine." It has been long suspected, and indeed rendered almost certain by a variety of facts, that the elec- trical state of the atmosphere has an appreciable influence upon the animal economy. The lower animals seem aware of an approaching thunder- storm, as would appear from the uneasiness which they manifest, the cries which they utter, and their running about in a stite of alarm in search of shelter. Many individuals also of the human species, particularly those labouring under certain chronic complaints, or who possess what may be called a great degree of mobility of the nervous system, experience at such times very peculiar sensations. Observations such as these, and many others of a similar description which might be quoted, demonstrate very completely that the ani- mal machine is frequently sensibly affected by the electricity of the atmosphere; and there is even nothing improbable in the conjecture which has been often hazarded, that the salubrity or insalu- brity of particular districts and seasons, the exist- ence and the character of epidemic diseases, are in some way connected with, if not immediately de- pendent upon, the same influence. Upon none of the many branches, however, of this interest- ing subject can we be said to possess positive knowledge. Experiments must be multiplied be- fore we can acquire data to reason with any pre- cision upon it Indeed it is only within a few years that these could have been instituted with any prospect of success. Our means of research are at present sufficiently delicate to enable us to commence such an inquiry with advantage; and it is much to be wished that meteorologists may henceforward register the variations in the electri- cal state of the atmosphere with as much diligence as those which occur to its temperature and pres- sure. T . James Apjohn. [ELECTRO-PUNCTURE. —Sec Galvan- ism.] ELEPHANTIASIS. There are two different diseases which possess this common name ; they are usually distinguished by the epithets Arabian, or of the Arabians, and Grecian, or of the Greeks. We shall treat of them under these terms. Elephantiasis Ababvh, (Elephant Leg.) The earliest account we have of this disease is by Rhazes, an Arabian physician, who lived in 850. In the Arabian language this affection is denominated dal fil, which imports literally mor- bus elephas, elephant disease. The Arabians sometimes contract dal fil into fil* alone, literally, elephas, elephant affection. This appellation was applied to the disease by the Arabians, in conse- quence of the huge misshapen appearance of the affected limb being supposed to bear some resem- blance to the form of the leg of an elephant. Elephant leg is known in the West Indies by the name of Barbadoes leg,- sometimes it is there denominated yam leg. from the supposed resem- blance the affected extremity has to the fantastic forms which this root occasionally assumes. In Ceylon it is called Galle leg, and on the peninsula of India it is denominated Cuckin leg, from its being indigenous to these places. In the Malabar language it is called anay kual, a term which, like dal til, imports elephant leg. Geographical Distribution. — This disease is in a remarkable degree endemic in the island of Barbadoes, on the south-west coast .,1' Crvlon in Ihe neighbourhood of Cochin, on the .\i;ilabar * Fil alfil, Arabic; ulfeel, Sanscrit; fit, u|fwa|j _i. pliant, Greek; elenhas, Latin.. (Thomson.) ELEPHANTIASIS. 771 Abyssini rC PartS °f JaPan' ™ ES'Pt' ™* in all of Ihw °TCUrS not unf">quently in almost mentenf% T India islands and »"** settle- ^nd t th "th America; in the Polynesian isles; Snl\Pr0V11nCeS of Castile and the Asturias «llJ .^ Pr l- Cases occur OVCT Eur°Pe gene- rally, and perhaps m all parts of the world. Persons liable to thia Disease.-In Bar- badoes elephant leg was, until about the year 1704, confined to the black population. A white in- habitant was attacked in that year , and before the year 1760, when he died, the disease was common among the white population. In general it would appear that imported Europeans are not liable to the disease unless they reside for a con- siderable time in the island. It is perhaps owing to this circumstance that soldiers are very rarely affected with it.* J In Ceylon the disease is confined to the indige- nous inhabitants, including the half-caste and Creoles. Imported inhabitants, comprehending Europeans, Africans, Malays, or natives of the peninsula of India, may be said to be exempted from its influence. There is only one instance known of a native of Europe having become af- fected ; and in his case the disease did not appear before he had been a resident at Point de Galle between thirty and forty years. Soldiers and other imported Europeans are not liable to it at Cochin. The disease affects all ages, although in general it appears in the early period of life ; and, in some rare cases, in the first year. Both sexes seem to be equally liable to it, and no condition of life confers an immunity from its influence. Individuals who enjoy every comfort, and who are not exposed to great vicissitudes of tempera- ture or changes of weather, are as liable to ele- phant leg as those who endure the hardships and privations of life. Symptoms.— The constitutional excitement, or primary stage of this disease, generally comes on suddenly, with rigors, headach, nausea, pain in the back and loins ; to these follow great heat of skin, alternating with profuse perspiration, and ardent thirst. Some particular part of the body (for, notwithstanding the name, the disease is not exclusively confined to the leg,) becomes red, hot, swelled, and painful, especially along the tract of the lymphatic vessels, so as to resemble, in some incisure, an erysipelatous affection. The febrile excitement becomes lessened in two or three days, and soon entirely disappears. This circumstance is followed by a cessation of the local inflamma- tory symptoms, the heat, redness, and pain; and the swelling becomes also greatly reduced, al- though the part affected rarely returns to its natu- ral size. Paroxysms of this kind succeed each other at intervals of various length, and frequently with some degree of regularity ; sometimes they occur as often as once a month, and at other times not oftener than once in six months. Every suc- cessive attack adds to the effusion and consequent morbid enlargement of the part affected. Every part of the body seems to be liable to * Dr. Hendy states that horses are liable to the disease in Barbarities, and thai it had been reported to him that dogs, horned cattle, and poultry, were sometimes affected with it. this affection. It has been observed in the head, the tongue, the neck, the breasts, the abdomen, the thigh, and the skin in general. The conden- sation of the cellular tissue of new-born or very young children is a form of elephantiasis. The parts most frequently affected are the superior and inferior extremities, the vulva, and the scrotum. The internal organs are also liable to become affected. Is it not probable that some varieties of enlargement of the liver, and the sarcomatous morbid structure of the ovaria and uterus, are kindred affections, if not the same ? Dr. Musgrave thinks this disease should be termed the migratory inflammation of the lym- phatic system. He says, « whatever may be its original seat, the patient is never secure, while the constitutional disturbance subsists, from a sudden retrocession to some vital organ. I have seen it in the same case translated from the scrotum to the head, from thence, after some hours, descend with the rapidity of lightning to the abdomen; again migrate to the chest, to return perhaps to the encephalon and prove fatal there; or, under more favourable circumstances, resume its compa- ratively harmless situation, and run its subse- quent course, as if nothing untoward had oc- curred ; and, while occupying the different cavi- ties, giving rise to the ordinary symptoms of acute inflammation of that particular viscus which it had selected for its temporary abode." (Edinburgh Med. and Surg. Journal, No. 92.) It is not common for more than one part of the body to become morbidly enlarged in the same in- dividual, although this circumstance sometimes occurs. A schoolmaster at Point de Galle had both arms and both legs affected. The scrotum is sometimes greatly increased in size : there was a mendicant at Galle, in whom it descended to the ankle, and who, when he sate to solicit alms, used to sit upon this part of the body, as he would have done upon the trunk of a tree ! The leg is, we believe, the part of the body which is most frequently affected, and sometimes it becomes enormously enlarged. Occasionally the swelling is uniform ; but commonly the skin is rough, rug- ged, and scaly, and the enlargement divided into unequal protuberances, which are intersected with deep fissures. The writer of this article was re- quested to visit a woman at Galle, who, although only about twenty-five years of age, had both of her inferior extremities so much enlarged and de- formed, that the back part of the legs rested upon the ground and projected behind the heel, about nine or ten inches. The fissures and interspaces between the projecting and pendulous protube- rances had ulcerated, and were discharging a most offensive sanies. Life could not be long preserved under such extensive disease. Organic Changes.—This disease is evidently, in the first instance, constitutional; and the local affection seems to be a result of some form of the process of inflammation, which recurs at intervals. A quantity of sero-albuminous fluid is effused from the exhalents into the cellular tissue of the affected part, which is not removed by adequate absorp- tion ; and the part of the body that may be affected becomes tumid, hard, and misshapen. Upon examination after death, the subcutane- ous tissue of an affected limb is found hard, dense, 772 ELEPHANTIASIS. and interspersed with small cells filled with serous fluid : the aponeurosis which covers the muscles is thickened, as also the cellular and intermuscu- lar tissue. The muscles are less red than natural. The arteries and veins are commonly not materi- ally altered. It deserves to be remarked, that the effused fluid in this disease is always coagulated; it con- sequently differs much from the serous effusions found in anasarca or ascites. It is still unascer- tained why it is so seldom absorbed, and so rarely excites inflammation and consequent ulceration. This effusion appears to be extra-vascular, al- though the fluid does not seem to have the effect •fan extraneous body. Remote Causes.—We know nothing satis- factory respecting the remote causes of elephant leg. It is admitted to be comparatively a new disease in Barbadoes, in as far as imported, if not Creole whiles are concerned; and no very import- ant change has been observed in the climate of the island. The aboriginal inhabitants of Demarara are not liable to this affection, although it is not rare among imported and Creole Africans and the half- caste. It occurs occasionally among the Creole whites; and perhaps there are about two cases of elephant leg in the colony among the imported Europeans. The progeny of Dutch families are more liable to morbid enlargements of the body than British Creoles. In this colony the disease is chiefly observed on the sea-coast. In Ceylon it scarcely ever occurs except among the indigenous inhabitants of about eighty miles, or one-ninth, of the sea-coast of the island. At Point de Galle, which is the principal village em- braced by the above range, the disease is extremely frequent; so much so that perhaps one-third, if not one-half, of the susceptible inhabitants are more or less afflicted with morbid enlargement of some part of the body. In other respects this is as healthy a portion of the island as any other: it is remarkably free from remittent or intermittent fever. Elephant leg seems to be endemic in the south-west coast only ; and persons who are re- gularly affected with periodic attacks in that part of the island escape a recurrence of the paroxysms when they change their place of residence to the interior, or to another part of the coast. Cochin is considered a very healthy station for troops. Exciting Causes.—The exciting causes are equally obscure. Drs. Hillary and Hendy attri- bute it to sudden changes of temperature; but we think without good foundation. We have known the disease affect nearly every member of a large wealthy family in Galle, the females of which, as they did not expose themselves to the sun, were not liable to a transition of temperature above ten or twelve degrees during a whole year. Dr. Hil- lary was of opinion that the local affection is a consequence of the precursory fever, while Dr. Hendy adopts a very different view of its patho- logy, and considers the fever to be a result of the topical inflammation ; asserting that unless the local affection is severe, there is no fever. In cases where the internal organs are affected, and the functions impaired, constitutional excitement may thereby be excited ; but it is difficult to con- ceive that a febrile affection should be the result of the chronic enlargement of an extremity. In some respects there is a considerable analogy between erysipelas and the disease in question. During the early stage of elephant leg the external characters of both diseases are similar. The topi- cal affection in either disease rarely terminates in abscess. In erysipelas the inflammation is, how- ever, commonly much more confined to the skin than in this disease; and so far as we are. acquainted with the latter affection, it differs from erysipelas in regard to its periodicity, or liability to recur at short intervals, without any appreciable cause.* Treatment.—The treatment recommended by Rhazes seems to be as consonant to reason, and as consistent with the pathology of disease as any that has been suggested. It consisted of general bleeding in violent cases; emetics, laxatives, a light diet, and confinement to bed. When an inferior extremity was affected, he recommended that the limb should be rubbed with an epitheme composed chiefly of alum and vinegar, and that it shouid be bandaged from the toes to the knees. The natives of Ceylon seldom resort to any other remedial means in this disease, but keep their couch, or rather their mat, and drink freely of ginger tea. Dr. Musgrave asserts that, " in addi- tion to warmth locally applied, and the ordinary purgative and febrifuge medicines, mercurial satu- ration of the system was the best means of securing the patient against the erratic disposition, and accordingly ptyalism was the usual companion of convalescence from an attack of this very common complaint:" for, he adds, " I am indeed strongly disposed to believe that, since the mercurial treat- ment has become general, the number of cases, ending in a local or permanent deposition of lymph, has been materially lessened." — "Many individuals subject to this disease, whom I have attended for a number of years, continued to shake off' each successive return without retaining the slightest trace of its having existed, or at most with a trifling induration of the inguinal glands." In the case of a young lady, at Point de Galle, belonging to a family, several of the members of which were affected with this disease, the first attack was treated by the free application of leeches and warm fomentations. Calomel was adminis- tered so as slightly to affect the mouth. A second attack which occurred shortly afterwards was treated in the same manner. Effusion did not take place, and no return of the disease was expe- rienced for the two years she was under observa- tion. When either of the great cavities was impli- cated, Dr. Musgrave had recourse to the lancet. Some of his medical brethren were afraid to bleed, from an » idea that the inflammation was erysipe- latous." He is of opinion, however, that "the redness differs little from that of phlegmon, and suppuration under the form of genuine abscess is an extremely common occurrence ; while, on the * Soldiers and sailors in the West Indies are frequently affected with smart alincks of an ephemeral fever, ac- companied with an inflammatory state of the lymphatics of the extremities. The writer of this note has seen, in such cases, a red line from the foot to the groin, indi- cating the course of the lymphatic trunk__J. F. Editor. ELEPHANTIASIS. 773 cations e*rernal gangrene is rarely, and vesi- | error hence arising has received, even in our own seems to"}, °i! "^^ observed" Dr' Musgrave day, still further countenance and circulation, by ttiseise ° i v.*- "tensive experience in this j its adoption in the splendid work of Alibert, and serves ' l-i i |)kn °f ,rei,tment certainly de- in the inv -a trial. It may, however, be observed that, "•circling to his doctrines, ptyalism should be the to T^w TT °f. i,imost evefy disease that occurs in the West Indies. Authors who have described this disease, gene- m.ly. if not universally, discountenance the ampu- tation of a morbidly enlarged limb. They assert that the constitutional symptoms are apt to recur, accompanied with inflammation of some of the viscera, or of an extremity ot tbe other side of the body. To amputate a limb while the paroxysm of fever continued to return, although at distant intervals, would, in the present state of our know- ledge of this affection, be injudicious; but if the recurrence of acute symptoms had ceased for a very long period, we should be much disposed to recommend the removal of a huge, deformed, and perhaps ulcerating mass of leg or arm. The writer amputated the arm of a native of Ceylon on account of an enormously enlarged forearm and hand, similar to the case recorded in the Edin- burgh Medical Journal, vol. xiii. page 54, by the late Dr. Kennedy. In this instance the man continued healthy, and no other limb became sffected. Cases have occurred, in which, in consequence of ulceration, a great quantity of a glairy fluid has been discharged, and the morbid enlargement has undergone a reduction to a very considerable extent. An artificial outlet of this kind has been tried in the scrotum, and, according to report, with advantage. Iodine, from the advantage wliich has been derived from it in goitre, might be tried with some prospect of benefit: the patient should always, if possible, be removed from the district where the disease is endemic J. Scott. Elephantiasis Ghscordm. ( Tubercular Elephantiasis.) Much confusion existed till very lately, in consequence of this term having been applied to two totally dissimilar affections. The Arabians, we have seen, appropriated the term answering in their language to elephantiasis to an enormously swollen state of the leg; whilst the Greeks designated by it the peculiar tubercu- lar disease which we are about to describe; the appellation being probably suggested to them either by the severity and protracted duration of the dis- orders, or by the. coar.seness and insensibility of the skin presenting some analogy to the rouch bide of the elephant. The tubercular elephantia- sis occasionally, also, received tbe name leonliasis from certain of the old Greek writers, in conse- quence of a fanciful likeness which they discovered in the stern and wrinkled visage, with its promi- nent brow and round eye, to that of a lion. It is the juzam of the older Arabians, and is still designated by a very similar name not only in A ,,ri;i, but also in Egypt, Persia, and India. The translators of the Arabian writers entailed additional obscurity on a subject already sufli- cr. illy involved, by rendering the Arabic word which indicates this tubercular disease, by the Latin term lepra, which is properly applicable only to the well-known scaly affection; and the J 3i»* invaluable system of Frank. Elephantiasis of the Greeks is characterized by the existence of numerous flattened qlossy tuber- cles, of a reddish or dark colour, varying in size from that of a split-pea to that of a large nut, and occupying usually the face, ears, or limbs. The skin is irregularly thickened and wrinkled, with a diminution ol its sensibility, and a swollen appear- ance of the affected part. The hairs fall off' from almost all parts of the body except the scalp. When a European is the subject of this frightful disease, the whole skin of ihe parts attacked becomes of a dirty brownish or bronzed colour, approaching to that of a mulatto. As the disease advances, some of the tubercles terminate in reso- lution, whilst others crack and ulcerate; these ulcerations, however, rarely become either deep or extensive, but furnish a glutinous matter which concretes into solid crusts, beneath which cica- trization usually takes place. The progress of each tubercle is quite independent of those in its neighbourhood, and is unaccompanied with pain, save in the ulcerated state. One of the most accurate descriptions of the disease is that by Dr. Kinnis, who saw several cases of it in the hie of France. The face was generally swollen, with large tubercles on the forehead, separated from each other by deep fur- rows ; and smaller and more confluent ones on the cheeks, which occasionally hung down, so as to depress the angles of the mouth; the alae of the nose were dilated, distorted, and covered with tubercles ; the ears thickened, enlarged, and stud- ded over with similar substances, and the lips penetrated by hard whitish bodies, which looked somewhat like recent cicatrices. In mulattoes the tubercles were of a light livid or copper colour, and in blacks a shade deeper than the surrounding skin. The cuticular lines and folds were every where more distinct and larger than natural. » The deeply wrinkled forehead, the bare swollen eyebrows, the heavy pendulous cheeks, the irregu- lar expanded nose, the depressed mouth, and the thickened elongated ear-lobes, combined to render the whole visage singularly harsh and uncouth." Similar reddish shining tubercles, but of a smaller size, usually exist within the rnouih, occu- pying the palate, uvula, and fauces, and frequently undergo a superficial ulceration : but this is attended with so little pain that the individual is often quite unaware of their existence, even when they are in the ulcerated state. The mucous membrane of the nose is occasionally implicated, being liable to an abundant discharge of matter, to hemorrhage, and even to ulceration. The sense of smell is often totally lost, the breath becomes very fetid, and the nose may eventually be flattened from the destruction of the septum- The frontal sinuses are sometimes attacked, as is, indicated by a dull pain in this region ; and the voice, in almost every instance, becomes nasal and hoarse, and affords evidence of the larynx being affected. The conjunctiva of the e\ e occasionally suffers, and the vision becomes in some degree obscured. The progress of the tubercles on the extremities 774 ELEPHANTIASIS. is altoeether similar to that of those on the face ; tb«»y develope themselves slowly, become inflamed, and subsequently pass into resolution or ulcera- tion. They are most numerous on the external surfaces of the limbs, whilst the inside of the thighs and arms, and the flexures of the joints usually escape. The skin of the fore arms and of the legs is often not only tuberculated, but also scaly and scabbed, and particularly so about the knee and elbow joints. In the case of a young man which we saw some years ajro in the Hopital St. Louis, at Paris, thin filmy scales were very evident between the tubercles. These existed chiefly on the face and arms, which were of a dirty brown colour, whilst the seat of old ulcerations was marked by still browner discolourations. There was consideiable insensibility in some of the diseased patches about the wrist. The case was of old standing, and accompanied by great emaciation and debility. Ulcerations of the ate nasi and throat had taken place, and the voice was much affected. But, although a slight degree of scaliness occa- sionally occurs, as in the above case, it is not a characteristic feature of the disease; for it is neither an original nor a universal symptom. The feet and hands are usually much swollen, and the motions of the joints greatly impeded by the tubercles. The nails are often coarse and furrowed. The sores are for the most part of an indolent character, with a reddish or a foul surface, little discharge, and hard and irregular edges. When the ulcerations are seated on the fingers or toes, they are apt to sink deep and terminate in gangrene; and a very serious mutilation of the extremities by the sloughing off of one or more of their phalanges is the consequence. The tubercles very rarely make their appearance on the trunk of the body. The parts attacked become, in a great degree, benumbed, but rarely, if ever, lose their sensibility altogether. Frank describes the disease as being accom- panied with great torpor of mind and sluggishness of body, somnolence, and disturbed sleep. Mental depression amounting to extreme melancholy is the natural consequence of so hopeless a malady. Yet the general health, for a length of time, suffers infinitely less than could have been anticipated ; the actions of the respiratory and digestive organs continue long unaffected, and even the cutaneous functions are still tolerably performed, as is evi- denced by the abundant perspiration which can be excited by active exercise. The pulse in Dr. Kinnis's cases was generally accelerated and feeble; but others state that it remains throughout the greater part of the disease n.itural. 'J'he affection has rarely been witnessed by a medical practitioner at its very commencement. In Mr. Lawrence's patient, whose case is detailed in the Medico-Chirurgical Transactions, it seemed to have begun by a general swelling of the head and face, and stiffness of the limbs after a wetting: on the subsidence of the swelling the tubercles began to appear on the ears, face, &c, which were at first of tho same colour as the surrounding skin, but became subsequently of a reddish and some- times of a livid hue. The progress of the disease is very slow, and its termination, though it may be deferred for many years, almost always fatal, the unfortunate patient being in the mean time dreadfully deformed and mutilated, and literally dying by inches. Recovery is, indeed, a very rare occurrence. In Mr. Law- rence's case the tubercles, it is true, disappeared in a great measure; but from the sudden impairment of the general health, which had been hitherto good, and from the simultaneous occurrence of thoracic symptoms, there was too much reason to apprehend that disease of the lungs had only sup- planted that of the skin. Dr. Adams has described as one of the symp- toms of elephantiasis as it occurs in Madeira, a femoral tumour situated in the upper and front part of the thigh. This was absent in the case which Mr. Lawrence has so ably described, but was found by Dr. Kinnis in most of those he had an oppor- tunity of examining — occasionally on one side only, but more frequently on both. It was placed a few inches below Pouparl's ligament, and was of an oblong form, as if arising from the enlarge- ment of two inguinal glands, and was about two or three inches in length, and moveable under the skin. At intervals of from one to four months, these swellings were liable to attacks of acute in- flammation, preceded by rigor, and accompanied with febrile symptoms, which subsided after three or four days, leaving the tumour nearly as before. These swellings have, however, in one or two instances been known to proceed to suppuration. As to the libido inexplebilis whicb has been mentioned as one of the features of the disease, a great diversity of sentiment appears amongst the authors who have treated of it. The majority of these (Vidal and Johannis, Bancroft, Niehbuhr, &c.) certainly affirm its existence, but Dr. Adams, on the contrary, asserts that the genitals become wasted ; or if the disease come on before puberty, their development is interrupted, as seems to have happened in Mr. Lawrence's case, in which the scrotum was shrivelled up and the testes were un- naturally small and soft; and in the four cases which fell under Dr. Bateman's notice, both the appetite and the power were lost. Dr. Kinnis, on the other hand, who had still more extensive opportunities of observation, did not meet with this wasting of the sexual organs in a single indi- vidual, the testes in males and the breasts in females being always of their natural size ; and the venereal appetite usually continued in its natural state. Menstruation is recorded to have been regular in two of the affected females, and a third had lately borne, and was still suckling, two children. From this want of accord amongst persons who have had abundant opportunity of observing the complaint, we are at least justified in concluding that increased sexual propensities are not amongst the essential characteristics of the disease. It is possible that still more extensive inquiry may reconcile the apparent contradiction amongst authors, and show that the tendency to diseased the organs of reproduction may be variously modi- fied by climate, or by peculiar local circumstances, which have hitherto escaped investigation. Altera- tions in the intensity of these feelings is not a very rare occurrence in some cutaneous affections • and it is not improbable that the extension of irritation and of morbid action to the urino-genital mucous ELEPHANTIASIS. 775 membrane may, in one stage of the affection, give rise to their unnatural exaltation, which may yet be followed, at a subsequent period and more ad- vanced stage, by the very opposite state. Patho- logy attords many analogous instances, in which alow degiee and an early stage of chronic irrita- tion in a secreting organ, leads to its increased action, whilst a higher degree of inflammation, or a more advanced period of the disease, often inter- rupts its functions altogether, and terminates in the atrophy of its structure. From a careful review of the evidence, both positive and negative, we are forced to conclude that the affection of the mammary and seminal glands, like the femoral tumour, is at most only an occasional complication. An account of elephantiasis, in some respects differing from that of other writers, has been given by Mr. Robinson, in the tenth volume of the Medico-Chirurgical Transactions. According to him it is one of the commonest diseases in Hin- dostan ; but there are two distinct varieties, and these have been usually confounded together. In the first variety, which, from the accompa- nying insensibility, he proposes to call E. anais- thetos, (the Barras of Ayicenna and the Soub- harry of the natives,) there appear one or two circumscribed light-coloured patches, which are shining, wrinkled, and on a level with the sur- rounding skin. These occur usually on the hands and feet, and are altogether insensible. They spread slowly till the surface of the whole body may be at length implicated, and its sensibility lost. There is neither pain nor itching, and usu- ally no swelling. After a few months the inter- nal functions become deranged, the pulse gets very slow and heavy, " as if moving through mud ;" the bowels grow costive, and there is much sluggishness of mind, and tendency to somno- lence. The skin of the extremities becomes fis- sured and rough, and ulcers appear under the metatarsal or metacarpal joints, the integuments seeming to be simply absorbed, or sloughing off in successive layers of about half an inch in di- ameter, without any previous tumour, suppuration, or pain. A sanious discharge ensues, the muscle, pale and flabby, is in its turn destroyed, and joint after joint drops off'. Yet the miserable sufferer clings to life, eats voraciously, and crawls about with little but his trunk remaining, till he is car- ried off at length by diarrhoea or dysentery. Mr. Robinson has never seen the larger joints attacked by it, the nose destroyed, or any bones affected Bave those of the hands and feet. The tubercu- lated species may occasionally supervene upon this variety, but they have no necessary or con- stant connection. The second species he mentions is the tuber- cular elephantiasis, which commences in the face by florid semi-transparent shining patches of cu- ticle; the skin becomes irregularly thickener!, and gives a bloated appearance to the face and ears. The arms, neck chest, and lower part of the trunk, and the legs, become subsequently affected. The skin of the tuberculated parts is not insen- sible, but is affected with heat and itching. A frequent sense of weight and pain in the head, with a lethargic state of mind, ensue. The pulse is slow and feeble, the voice hoarse, and the bones of the nose and palate often become carious. It is in this species alone, and in its commencement only, that the venereal passion is increased. In the after stages the testicles are absorbed. The fingers and toes do not, at least till a very late period, become at all numb. Bateman, though his description is in most respects accurate, has, Robinson thinks, in some points confounded these two varieties. The dropping off of the fingers and toes, the insensibility of the skin, and the ex- treme torpor of mind and body belong to the first; the tubercles, ulceration of the palate, and affec- tions of the cartilages and bones of the face, to- gether with the frequent occurrence of the oblong glandular swelling in the groin, to the second. The mudar, which is so useful in the first species, is injurious in the other; for which last arsenic is the best remedy. Our knowledge of the morbid anatomy of ele- phantiasis is still very imperfect both as regards the state of the skin, and of the subcutaneous cel- lular membrane. The epidermis is extraordina- rily thickened, and the tubercles themselves have by some been described as solid fatty tumours rooted in the true skin, whilst others speak of them as small cysts containing a reddish glutinous fluid. The cutis vera has usually been found in- flamed in those spots only, when the tubercles were in a state of relaxation and suppuration. The subjacent muscles and tendons have been, in some instances, observed to be matted together. The immediate cause of death has, in most cases, appeared to be the extension of inflammation to tbe mucous membrane of the trachea and pha rynx, and to the lungs. As to the causes which give rise to this affec- tion, little is with certainty known. Its origin has been ascribed to want of cleanliness and to unwholesome diet, especially the constant use of bad fish; to long-continued exposure to the heat of a tropical sun, by some writers ; and to damp- ness of situation, or occupations requiring the frequent immersion of the limbs in cold water, by others. The number and incongruity of these supposed causes naturally dispose us to attach little credit to any of them. There is strong rea- son to believe that it is occasionally hereditary. A few instances favourable to the notion of its being propagated by contagion are on record ; but, on the other hand, innumerable examples of indi- viduals having been exposed for years with impu- nity to the closest contact with the diseased, as in the case of husbands and wives, parents and chil- dren, &c, throw much doubt on the reality of this mode of origin, and force us to attribute its occa- sional propagation in a family, either to hereditary predisposition, or to exposure to similar exciting causes, or both. The disease occurs chiefly in warm climates. Arabia, India, Africa, Madeira, the Isle ol France, and some of the West-India Islands, (into which last it is supposed to have been introduced by the slave-trade,) are amongst its chief localities. But northern latitudes do not enjoy a perfect ex- emption from its ravages, for in Norway and Ice- land, elephantiasis, or at least a very similar dis- ease, (spedalskhed, radesyge, liktrea,) occasion- 776 ELEPHANTIASIS —EMETICS. ally prevails.—(See Hufeland's Journal for Oc- tober, 1819, Henderson's Residence in Iceland, &c.) The pellagra of the Milanese territory, the rosa Asturica of Spain; the Crimean disease mentioned by Pallas and Gmelin, as occurring in the neighbourhood of Kherson and of Astracan; and the mal rouge of Cayenne, are all closely allied to it. Of the treatment of a disease which is almost always incurable, all that need be said may be comprised in a few words. A mild unstimulating diet, tepid baths, and soothing applications to the skin when in the ulcerated state, are points in the propriety of which all are agreed. The use of sarsaparilla and guaiacum, and of mild alterative doses of mercury with antimony, have, along with change of residence, occasionally produced a tem- porary amendment. In the case at the Hopital St. Louis, to which we have already alluded, though it was in a very advanced stage, considerable improvement was effected by the use of such simple means as the following, viz. confining the patient to a milk diet and mucilaginous drinks, along with minute doses of opium, and baths to allay irritation. This pa- tient was under the care of M. Biett, one of the most enlightened and least exclusive practitioners in Paris; and a great variety of more energetic treatment had previously been employed with no permanent benefit. All agree that the large employment of mercury aggravates the disease, and this, too, is often the case with arsenic, though in the form of the Asiatic pills, in which it is combined with black pepper, it enjoys a high reputation among the native phy- sicians in the east. Bark has been extolled by Dr. Thomas Heber- den, in Madeira, and the mineral tonics have been recommended by others. Dr. Schilling, at Suri- nam, found much benefit from the use of the warm bath, and stimulant vapour baths, spirituous fric- tions, and gentle exercise; and, in truth, the more frequent occurrence of the disease on the extremi- ties than on the trunk, renders it probable, that it is somehow connected with deficient vitality, or imperfect circulation in the skin of these parts, and justifies the employment of such measures. From observing a temporary amelioration to take place on the occurrence of an erysipelas, and from the fact that the spontaneous subsidence of each individual tubercle is usually preceded by a degree of inflammatory action, it has been inge- niously proposed by Rayer to excite a slight de- gree of inflammation in the diseased skin by the u*e of stimulant applications, such as ammoniacal liniments, tincture of cantharides, ointments con- taining hydriodate of potass, &c. Should their action prove too irritating, he directs us to alter- nate their employment with that of the warm bath. With the view of promoting absorption, the inter- nal use of iodine might also be tried. W. B. Joy. EMETICS, (Qdpuaica Iptrucd, emelica; from !,*{<*, vomo.) Emetics may be defined—substances which cause the ejection of the contents of the stomach by the mouth, independently of the stimulus of quantity, or of the influence of any- nauseous taste or flavour. When these substances, with a few exceptions, are taken into the stomach in certain quantities, they do not immediately operate, but produce an uneasy sensation attended with nausea, which increases, and terminates in vomiting. Even before vomiting commences, the influence of the emetic substance is not confined to the stomach. As soon as the nausea is felt, the countenance becomes pale; and the pulse, diminished in strength and frequency, is quick and irregular. There is occasionally great anxiety, listlessness, and depression of spirits, with a ten- dency to fainting; at length sweat breaks forth, and just before vomiting commences, a peculiar sensation is experienced at the clavicles. After the vomiting has begun, the face flushes, the pulse is quickened, and it remains so betwixt each effort of vomiting, which occurs several times in succes- sion, at short intervals, before it ceases. The nausea now subsides, either at once or by degrees, leaving a transitory feeling of depression, which makes the patient indifferent to everything around him. When emetic substances, with the few excep- tions to which we have already alluded, are re- ceived into the stomach, they do not operate by any local stimulating influence on the coats of that organ; the time which elapses alter they are swallowed sets aside such an opinion ; and there exist other sufficient reasons for affirming that they are absorbed and carried into the circulation before vomiting is induced. When a solution of tartar emetic is injected into the jugular vein, it produces vomiting sooner than if it had been swallowed; and an experiment of M. Magendie has demonstrated that vomiting produced by an emetic substance may be stopped by pressure made upon the medulla oblongata. Now the in- ference that may be drawn from this fact is, that the action of emetics is not owing to any local stimulus on the nerves of the stomach, but to the action of the emetic substance, after being absorb- ed into the circulation, as a direct stimulus to the origin of the nerves, whereby contractions of the stomach, and the actions of the other muscles concerned in the act of vomiting, are induced. These nerves comprehend a branch of the eighth pair, the intercostal, and the phrenic nerves. It may be inquired — what is the nature of the irritation which excites vomiting .' Does it depend on the physical character of the particles of the substance employed ? or is it the result of some chemical or electro-chemical change ? These are queries which cannot be satisfactorily answered : all that can be said is, that there is, probably, something connected with the substances which cause vomiting, which has the power of irritating a particular set of nerves only : for were this not the case, why should tartar emetic, when injected into the jugular vein, excite vomiting ? Vomiting may be produced by a variety of causes, either connected directly with the stomach itself, or indirectly, by sympathy with it through the medium of the nervous system. 1. Vomiting may be directly induced by food undergoing changes inconsistent with healthy digestion; by mechanical irritants lodging in the stomach; by tumours pressing on the pylorus- by inverted actions of the intestinal canal, forcing EMETICS. 777 th bile d'.n|!ntS °f- tlle- <3uo<*enurn> particularly the l sions, in which the utmost contraction of the dia- the str ° ,r5e(^ Int0 il fr.om ,ne bil«ary duct, into j phragm and abdominal muscles is required to the sons °m ' .by chem»cal acrids and other poi- ! compression of the viscera." the mil\ emet!C substar|ces taken into it; by any j M. Magendie, in an able memoir published in r est substances, when inflammation of it's ! 1813, supports the opinion of Chirac. (See also coats, or ulceration, augments its nervous irrita- bility. 2. Vomiting may be indirectly induced bv strangulations of the intestinal caml : by the ir- ritation artsing from biliary or renal calculi im- pacted in the excretory ducts of the liver or of the kidneys: by titillation of the fauces; by inflam- mation of certain portions of the contents of the cranium, for example, of the arachnoid membrane covering the base of the brain ; by repelled cuta- neous eruptions ; by emetic substances injected into the veins; by sailing, swinging, riding in a carriage, and other movements of the body; by pregnancy ; by the influence of certain odours"; and by mental impressions. Whichever of these causes produces vomiting, a specific action of the stomach, and the consent of certain muscles of the thorax and the abdomen are, in every instance, necessary to produce the effect : thence the ques- tion, in what manner is vomiting effected ? In replying to this query, let us first enquire what opinions have been advanced regarding it by others. M. Chirac (Histoire de l'Academie des Sciences, 1686) first suggested the opinion that the stomach is passive during vomiting, which he contends is effected solely by the action of the diaphragm and the abdominal muscles; an opinion afterwards adopted by Duverney, Bayle, and John Hunter. M. Litre denied the influence of the abdominal muscles, and maintained that the diaphragm is the chief agent in producing vomiting. Lieutaud and Haller supported the idea that the stomach is the real agent; the former founding his opinion on having observed, in a patient who could not be made to vomit by the most powerful emetics, that the stomach was greatly distended and insensible. Sir Charles Bell (Anatomy of the Human Body, vol. iv. p. 54) appears to hold nearly similar opinions to those of Lieutaud upon this sub- ject. "That vomiting," says he "may be pro- duced by the inverted motion of the stomach and diaphragm alone, is apparent from experiments upon living animals, where the abdominal mus- cles are laid open, and from cases in which the stomach has rested in the thorax, and yet been excited to active vomiting." He also states that the walls of a stomach in his possession "had be- come so thick that they could no longer suffer contraction by ttie muscular fibres; the conse- quence of which was, that although the inner coat of the stomach was in a raw and ulcerated state, there was no vomiting." Sir Charles, how- ever, modifies this opinion by remarking "that, when the stomach is excited to vomiting, there is consent of the abdominal muscles, by which they are brought into violent spasmodic action; not alternating in their action, as in the motion of respiration, but acting synchronously, so as great- ly to assist in compressing the stomach ; but," he adds, "at the same time, the action of these mus Precis Eltmentaire de Physiologic vol.ii. p. 140.) In one of his experiments, he drew the stomach ! through an opening of the abdomen, thus freeing j it from the influence of the diaphragm and ab- dominal muscles, and he found that vomiting could not be excited. He also ascertained, that I if all the abdominal muscles be removed, leaving only the linea alba, vomiting still occurs from the stomach being pressed, as he supposes, between that part and the diaphragm. In another experi- ment he states that he substituted a pig's bladder for the stomach, and nevertheless, vomiting took place ! He found that the division of the phrenic nerve weakens the action of vomiting, but does not altogether prevent it. These experiments prove—1. that the influence of the nervous system is essential to the produc- tion of vomiting; 2. that the abdominal muscles greatly influence the ejectment of the contents of the stomach. But they do not satisfactorily ex- plain the action of the diaphragm, nor the part which the oesophagus bears in the operation of vomiting. Dr. Richard Harrison, in his Gulsto- nian Lecture, adopts the opinions of Chirac and Magendie, as far as regards the action of the dia- phracrm and the abdominal muscles; but he adds to this call upon the expiratory muscles through the agency of the brain, and their consequent ac- tion, the contraction of the stomach itself. There can be no doubt of the agency of the nervous system in this operation; the only question is, whether the excitement be first exerted on the extremities of the nerves of the stomach itself, from which the impression is communicated to the brajn by sympathy, and the auxiliary muscles be thus called into action : or whether, as the writer of this article imagines to be the case, the impression is made upon the spinal marrow from the absorption of the emetic substances, and through the influence of the motor nerves to the respiratory muscles, so that all the machinery con- cerned in the operation is excited into simulta- neous action. Dr. Marshall Hall has endeavoured to prove that Magendie's assertions respecting the influence of the diaphragm are incorrect, and that the act of vomiting is in fact a forcible expiratory effort. He contends that, if the diaphragm contracted, as Magendie affirms, the act of vomiting would be attended by inspiration ; that the glottis, in such a case, would necessarily be open, and that the fluids ejected from the stomach would be drawn into the larynx, and induce great irritation there; an event which does not occur in vomiting. On the contrary, as M. Magendie admits, although he contends for the agency of the diaphragm, the larynx is accurately closed at the instant that the vomited matter is passing through the pharynx. Dr. Hall's explanation of the mechanism of vo- miting is this: " the contents of the thorax and abdomen are subjected to sudden and almost spas- cles however forcible their contraction, cannot modic contraction of all the muscles of expiration, alone cause vomiting; nor has this action any the larynx being closed so that no air can escape tendency to produce such an effect on other occa- , from the chest, and the two cavities being made Vol. I.—98 779 EMETICS. one by the floating or inert condition of the dia- phragm." The mere mechanism of vomiting, therefore, according to Dr. Hall, "differs little from that of coughing, by which indeed the con- tents of the stomach are frequently expelled: the larynx in the former is, however, permanently, in the latter, only momentarily closed ; and there is doubtless a different condition of the cardiac ori- fice and of the resophagus." In order to confirm his opinion, Dr. Hall made an opening into the trachea of a dog, which was excited to vomit by subsulphate of mercury ; during the act of vomit- ing, the air from the lungs was forcibly driven through the artificial opening. Dr. Hall, in his explanation, admits the influence of the oesopha- gus, and adds, "it is plain that the cardiac orifice must be freely opened; for mere pressure upon the viscera of the abdomen will not, in ordina- ry circumstances, evacuate the contents of the stomach. To effect this open state of the cardiac orifice, it is probably necessary that the dia- phragm should, indeed, be in a relaxed rather than in a contracted state." There is much inge- nuity and considerable truth in this theory; but it does not wholly explain the operation of vomit- ing. The following opinion of tbe writer of this article may be regarded as a modification of that of Dr. Hall. He admits that it is true that the glottis is closed, and that a powerful effort is made as if of expiration ; but this effort is not altogether that of expiration ; for, whilst there is a powerful and sud- den contraction of the abdominal muscles, forcing up the whole contents of the abdomen towards the thorax, the diaphragm is fixed, owing to the clos- ing of the larynx, and the retention of the quan- tity of air which the lungs contained at the com- mencement of the effort. The diaphragm is thus prevented from ascending into the chest; and the pharynx being drawn up as in the act of degluti- tion, opens the cardiac orifice of the stomach, and forms with this viscus one continuous cavity. This open state of the cardiac orifice of the sto- mach, forming one continuous cavity of the sto- mach and pharynx, explains an observation of M. Magendie, tbat " during the state of nausea which preceded vomiting, in some of his experi- ments, air was drawn into the stomach." Now, if it be true that the cardiac orifice of the stomach is open, and the mouth, the oesophagus, and the stomach be one continuous cavity, it is evident that the external air, which is heavier than the air and vapour contained in the stomach, will ne- cessarily be forced into this organ by its mere gra- vity, as it would be into an ordinary receiver con- taining vapour and little or no air. In this state, by the sudden compression of the stomach by the abdominal muscles drawn forcibly and suddenly inwards, the diaphragm being fixed, the contents of the stomach must be directed upwards, with a degree of force commensurate to the suddenness of the pressure upon its walls; and consequently they are thus ejected by the mouth. If this de- scription be correct, it is evident that the act of vomiting is the result of the simultaneous action of all the muscles of respiration, at a moment when the glottis is shut, and offers resistance to the ascent of the diaphragm. Dr. M. Hall is correct in describing it as un expiratory effort; but this effort alone would not effect vomiting, were there not the resistance which has been described op- posed to it. The stomach, therefore, is in every respect passive; and it is not obvious that con- traction of that organ forms any part of the pro- cess of vomiting ; it is rather in a state of relaxa- tion than of contraction. Thus, if a bag half filled with fluid, with an open tube rising from it, were suddenly struck or compressed, the fluid would be ejected through the tube; but if, at the same time, the bag was also contracting its general capacity, the impulse of the compressing force would be ne- cessarily diminished, and the impetus of the eject- ment of the fluid considerably weakened. Such is the view of this operation taken by the writer of this article : but in whatever manner it is accomplished, there can be only one opinion re- specting the share which the nervous system has in the operation. «• This act, (vomiting,) will not take place," justly remarks Dr. Paris, " however forcibly the stomach may be goaded by emetics, where the energy of the nervous system is sus- pended, as in cases of profound intoxication, or in violent wounds or contusions of the head; while, if the brain be only partially influenced, as by in- cipient intoxication, or by a less violent blow upon the head, its irritability ift increased instead of be- ing paralysed, and vomiting under such circum- stances is excited by the slightest causes." (Phar- macologia.) The first effect of the influence of an emetic on the system is the production of nausea, and a consequent diminution of general excitement: this is followed by the ejectment of the contents of the stomach, and an alteration in the condition of its secreted fluids : thus, for example, in dyspepsia not only do emetics eject any superabundant acid contained in the stomach ; but they also so influ- ence the functions of the secreting follicles, that for some time all acid totally disappears. Along with the contents of the stomach, bile is also ge- nerally ejected, owing to the compression of the liver and the gall-bladder forcing a large quantity of this secreted fluid into the duodenum and the stomach. In the act of vomiting, also, all the ab- dominal viscera being compressed, the blood is propelled more forcibly through their vessels; thence a change is effected on tbe intestinal secre- tions, and on those of the pancreas and the spleen : even the kidneys are affected, and the quantity of urine is considerably increased. The pulmonary system is also influenced, a freer cir- culation of the blood through the lungs is pro- moted, and the action of the secreting and exha- lent vessels is augmented. But, besides these effects of emetics on the particular organs, the re- sult of their influence on the general system is the equable distribution of the blood to every part of the body ; and the consequent removal of local determinations and congestions. How far these effects depend in part upon the absorption of the emetic substance is yet to be ascertained. Emetics operate as evacuants in other respects than by emptying the stomach : they induce dia- phoresis, and by stimulating the capillary system and thereby checking the effusion of serous fluids into the cavities of the body, enable the absorbents to carry off any fluid already accumulated there: hence their utility in dropsical affections. By the EMETICS. T79 nausea, also, which attends their operation, abating e torce of the circulation, they have sometimes 41 k"Seful 'n active hem°rrhagcs. Although all the substances classed as emetics accord in producing more or less nausea and vomit- ing, yet they differ in some circumstances. I. Emetics d ffer in the time required for pro- I ducmg their effects.-The sulphates of zinc and of copper operate the quickest of all the emetic substances in common use, exciting vomiting almost as soon as they are swallowed. Tartar emetic, and the other active antimonial prepara- tions, and subsulphate of mercury, operate quickly also, but less so than the salts of zinc and of cop- per; whilst all the vegetable emetics are still more tardy in producing vomiting. This diversity in point of time has not been satisfactorily explained: it has been supposed to depend on the solubility of the emetic substance in the gastric juice, and its consequent application to the extremities of the nerves of the stomach being thus more or less facilitated. But, independently of the fact that all emetics, with the exception of the few which operate by their direct influence on the nerves of the stomach, are absorbed before they produce their effects, there is no evidence of this action of the gastric juice; and^ubstances already in a state of solution are influenced by the circum- stances, whatever these may be, which produce this diversity. Two substances held in solution in the same solvent, and conveyed into the stomach under the same circumstances, differ considerably in the time which elapses before they operate. Thus a solution of tartar-emetic in wine operates sooner than a vinous solution of ipecacuanha; although, were both these substances in the solid state, and were the action of the gastric juice on them requisite for their operation, it is probable that the vegetable substance would be the most readily dissolved, and consequently operate most quickly ; but the reverse is the case. It is proba- ble that the diversity depends on the more rapid absorption of the antimonial salt than that of the emetina, the active principle of the ipecacuanha, after both have passed the pylorus. The time required for the operation of different emetics should be familiar to the physician, as much of the benefit to be expected from this order of reme- dies sometimes depends upon this circumstance. 2. Emetics differ in the degree and the severity of their effects. — The saline emetics in general operate more violently than the vegetable emetics; but the latter cause a more severe and longer-con- tinued nausea. It is not easy to account for these effects, unless we admit that, although the first impression of the saline emetic on the nervous system be the most energetic, yet, that the saline substance is more readily decomposed, or thrown out of the system, than the vegetable. It is of much importance, in a practical point of view, to attend to the degree of energy of opera- tion of different emetics, and to avoid any risk connected with their violent action. Emetics do not operate with much energy on persons oi torpid habits ; larger doses are required than in ordinary cases; and, not unfrequently, vomiting cannoi be excited by any dose. When this is the case, emetics cause great anxiety and uneasiness. Per- sons of a sanguine habit are more easily affected by emetics than those of a melancholic; women than men; children than adults: thence experi- ence has informed us that, in febrile affections, vomiting is a common symptom in such persons. It is of some importance to know how to anticipate the degree of difficulty or facility with which dif- ferent persons can be excited to vomit, seeing that not only those who are not easily excited suffer from pain and anxiety, but those who are very easily affected are apt to be injured by even the ordinary dose of an emetic. Emetics are contra-indicated in some conditions of the system. In all cases in which the phlogistic diathesis prevails, they ought not to be adminis- tered until after bloodletting and purging have been employed. They have, nevertheless, been found very beneficial in some inflammatory affec- tions. In croup they are supposed to be specially indicated: Dr. Crawford, and many subsequent writers on that disease, recommend them to be administered in the earliest stage of it: others, however, urge the propriety of waiting until the inflammatory action be at least mitigated by the use of the lancet, calomel, and purgatives. In those cases in which we have seen them employed in the commencement of the disease, much less assistance has been required from bloodletting than when they have not been given. We must ad- mit, however, that when the inflammatory symp- toms run high, they are at least of doubtful efficacy. In pneumonic affections, also, if the state of the bronchial cavities require the influence of an emetic to aid expectoration, they ought not to be employed until after the excitement has been reduced by the proper use of the lancet. As pres- sure is necessarily applied to the descending aorta during the action of vomiting, there is a temporary interruption to the pulmonary circulation, and the blood is returned with difficulty from the head ; consequently vomiting should not be excited in states of the habit predisposing to apoplexy. From the compression, also, of the abdominal viscera, the administration of emetics requires caution in those afflicted with hernia and prolapsus of the anus or of the uterus; nor are they always ad- missible in the advanced stage of pregnancy. The spontaneous vomitings which attend the early stage of pregnancy are sufficient guarantees of their safety at that period. In diseases of debility, and in weak and delicate subjects, emetics, espe- cially those which nauseate, should be carefully avoided. Experience has also proved that the frequent employment of emetics is injurious, pro- ducing general debility, and such an irritable state of stomach that it is excited to vomiting by the most trifling causes, even by changes in the nature of the food; indeed no means are so likely to induce dyspepsia as the custom of taking frequent emetics.* * This remark is, apparently, at variance with the custom of the Komans. Emetics were daily taken to enable them to relish ihe enjoyments of the table ; and so far did the Romans carry this custom, that they some- times excited vomiting to eject from the stomach what Ihey had eaten in one course, that tiny might he the mure capable of enjoying what was to follow. Accord- ing to Seneca, ' they vomited that they might ent, and ute that the) might vomit." They employed emetics before meals, that they might he able to eat more pleuti fully; and they often concluded a feast with an emetic, to prevent the consequences of gluttony. In one of Ci- cero's epistles to Allicus, he describes a visit wliich he 780 EMETICS. With respect to the period of the administering emetics, much must depend on the circumstances of the case which demand their employment.* If there be no immediate urgency, the evening is the best time; for as the body is always more or less exhausted by the operation of an emetic, the tendency to sleep which supervenes can then be readily indulged. Attention to the period for ad- ministering emetics is particularly requisite in fe- brile affections. Thus when they are necessary in continued fever, the time of day for adminis- tering them with most advantage must not be overlooked. In almost every continued fever there is a mid-day and an evening exacerbation. These are not always very obvious : the evening one, however, is the most so; and its approach is marked by increase of pulse, thirst, headach and dry hot skin. It is immediately prior to this ac- cession that emetics will be found most useful, sometimes checking it altogether, at other times at least diminishing its violence. In reference to the operation of emetics, we may remark that the dose of the emetic substance should be sufficient to produce full vomiting, otherwise nausea and restlessness, instead of vo- miting, will follow the administration of the medi- cine. It is the custom to order warm water to be freely drunk during the operation of an emetic. This certainly promotes its action if the fluid be taken after each time of vomiting; but it is re- quisite to be cautious that too much is not taken at once. The stomach, when oppressed with water, does not yield to the action of the muscles which are excited to produce vomiting, thence it is in danger of laceration. There are several in- stances on record of this having occurred ; but it may be questioned whether rupture ever happened, unless the organ was previously diseased ? The quantity of fluid for an adult should not exceed two-thirds of a pint at a draught; it should be tepid, and, if the stomach be weak, some bitter infusion, as, for instance, that of camomile flowers, or a few drops of liquor ammonia in the water, should be employed to aid the action of the eme- tic. If the vomiting be severe and long-continued, it may be checked by solutions of neutral salts ; sulphate of magnesia, for example, or citrate of potassa, formed with the carbonate of potassa and fresh lemon-juice, given in a state of efferves- cence ; or a teaspoonful of magnesia may be given in a glass of sherry ; or solid opium or hydrocy- anic acid may be administered in small doses.-f- All substances employed to excite vomiting may be arranged in two classes—direct and indi- rect emetics. I. Direct Emetics are substances which cause vomiting by an immediate impression on the nerves of the stomach. It may be asked, how made to Osar, at his villa near Rome; and states that his dignified host paid him the compliment of taking nn emetic before dinner, when he understood that Cicero intended to spend the day with him. * Some of th<> old writers, StoU in particular, regard Ihe period of the day as a matter < f indifterence. Rat. Med. 11. t Many other means may be cinplnvci* to check vomit- ing ; as, for instance, the administration of snlinitrate of bismuth, infusion ot calnmba. strong rnrTee, tincture of capsicum diluted with water, in that induced bv preg- nancy and sailii:ir;-a lar^-a dose of caluuiel, and dry cupping ou the epigastrium. | can this take place, if the stomach be a passive agent in the act of vomiting 1 We reply, that by the term passive agent we do not mean to assert that the stomach is insensible to the stimulus of all emetic substances; on the contrary, all irri- | tants, whether chemical or mechanical, are capa- ble of stimulating the stomach to vomiting; but, nevertheless, in this operation, the stomach is not the active agent. This seeming inconsistency may be thus explained. When the stomach is I in the performance of its natural function, the I digested food is pushed forward to the pyloric ori- | fice ; but if the chymification be not complete, it is again thrown back into the fundus, and occa- sionally into the pharynx, producing eructation; a circumstance, however, which occurs only when | the secreted juices of the stomach are in a morbid j state ; and, under this condition, the ejectment re- j sembles in every thing but degree that produced I by emetics. In a similar manner, when a large I dose of sulphate of zinc, for instance, is swal- lowed, its immediate application to the nerves of the fundus of the stomach produces a spasmodic I contraction there, which throws the whole con- tents of the viscus mixed with the sulphate upon the pylorus; but these are as rapidly returned, even before the relaxatjpn which must follow the spasmodic contraction have taken place; and by this means, the emetic substance being applied to the nerves of the cardiac portion of the stomach, the muscles and every otlier part necessary for effecting vomiting are simultaneously called into operation, and vomiting takes place. This is the opinion of the writer of this article, and he con- ceives that it is the only theory capable of ex- plaining the immediate emetic influence of sul- phate of zinc, sulphate or acetate of copper, and carbonate of ammonia. These substances, when taken into the stomach, first hasten, in a spasmo- dic degree, that action of the organ which carries the food forward to the pylorus; and there acting contra naturam, instead of opening the pyloric orifice, they are thrown back upon the cardiac portion of the stomach, the nerves of which being suddenly impressed, call into play all those sym- pathies which operate to produce the action of vomiting. If this theory be admitted, it may be applied to explain not only the vomiting caused by powerful irritants when swallowed, but those also which occur in cancerous affections of the pylorus, and in the early stages of pregnancy. Thus, in cancer of the pylorus, when food is taken into the stomach, no vomiting occurs until it is pushed forward to the pylorus, which, being mor bidly excitable, throws back the food mixed with acrid matters, the result of the disease, and these acting on the sentient extremities of the eighth pair of nerves spread on the cardiac portion of the stomach, the muscles of the abdomen and those of respiration are instantly called into action to relieve the stomach of the offending matter. In pregnancy, again, the sympathy between the sto- mach and uterus is such, that the disturbance of I the former is in the direct ratio of the energy of I the latter; digestion, therefore, becomes depraved the chyme is imperfectly formed, and, mixed with the acrid secretion, is thrown back from the pylo- rus, and applied to the cardiac nerves, and voinit- | ing is necessarily excited. EMETICS, 781 scrfh^Sta"CeS Wh'ch aot in the manneT j"st de- Th arn lh°Se whirh ronsti,ute direct emetics. neir operation is preceded by no nausea, neither s any |eft behind aftpr h .^ comp]eted_ Emetics ( trns cuv,s10n, therefore, are adapted for pro- ducing fun and in,mediate vomitinK5 in tho9e con. di ions of the habit in which tbe exhaustion caused »y nnuaoa woulJ be injurioug) but jn which it is nevertheless necessary to unload the stomach. I hey are also the most useful in cases ot poisoning, not only „n account of the rapidity of their operation, but from their action not being followed by absorption, which, in such instances, would prove highly prejudicial. Direct emetics are tew in number, and are all inorganic sub- stances. 1. Ammonia. If the officinal solution of am- monia, to the extent of half a fluidrachm, be swallowed in a cupful of cold water, and the same quantity of tepid water be taken immediately af- terwards, it excites instant vomiting. But as un- toward circumstances have occasionally followed the administration of the solution of pure ammo- nia, it is rarely employed as an emetic; the car- bonate, in doses of from ^ss to 31 being given in its stead. It has been found serviceable in those cases of chronic catarrh. 4n greatly debilitated ha- bits, in which expectorants cannot with propriety be administered. In such a state of the system, the act of vomiting, induced by the ammonia, aids in unloading the bronchial tubes, whilst, at the same time, a salutary stimulus is given to the nervous system ; and the expectoration, which in general is suspended in such cases, is again brought on. When administered in larger doses, ammonia operates- as an irritant poison, and re- quires the immediate administration of vinegar to neutralize and obtund its acrimony. (See Toxi- cology.) 2. Sulphate of zinc. This is a more safe di- rect emetic than ammonia, and equally powerful in its effects. It excites no nausea, and operates as soon as it enters the stomach, producing a sin may here be permitted to remark, that emetics have been regarded as specifics, and have been prescribed in every stage of this disease. •• It is remarkable," says Dr. Young, " that a very great majority of the cures of consumption, which are related by different authors, have either been per- formed by emetics or by decidedly nauseating re- medies." (Young's Practical and Historical Trea- tise of Consumptive Diseases, &c. p. 65.) They were employed in this disease by Hippocrates, whose emetic was a compound of honev, vinegar, and water; (Hippocrates on Int. Aff.) and by Galen, who followed the example set by the father of physic. Bennett, Morton, Etmuller, Wain- wright, Russell, Bryan Robinson, Marry at, Don- ald Monro, Macbride, and many other equally distinguished physicians speak also favourably of their effects. The confidence of Dr. Reid and Dr. Simmons in the use of emetics in phthisis was unbounded. Dr. Mackittrick Adair held al- most as sanguine an opinion of their beneficial influence as Dr. Reid : he gave first a pint of warm water, then a grain of sulphate of copper with a drop of dilute sulphuric acid in half an ounce of water every other evening for three days ; then every morning. (Duncan's Commen- taries, 1791; p. 473.) Notwithstanding these strong testimonies, truth obliges us to state, that the method of treating phthisis with emetics has not succeeded in our hands, nor in those of many of the most distinguished men who, at different periods, have adorned the profession. If emetics, however, be employed, those which operate di- rectly, the sulphates of zinc and of copper, should be preferred. The dose of the sulphate of cop- per is from ten to fifteen grains dissolved in three ounces of water. In cases where it has been over- dosed, the best antidotes, after the use of the sto- mach-pump, are ferrocyanate of potassa, milk and albumen. II. Indirect Emetics are obtained both from the organic and inorganic kingdoms of nature. Indeed, whatever disturbs the energy of the brain gle but copious ejectment : it is, therefore, well | to a degree sufficient to affect the stomach by adapted for cases of poisoning, and to excite vo- miting in the commencement of the paroxysm of ague, when we are desirous of breaking the mor- bid association which keeps up tbe disease, by giving sui h an impulse to the system as will pro- pel the blood to the surface, and equalize the cir- culation. In cynanche tonsillaris, when abscess forms in a situation which cannot be readily reached by the knife, and yet does not seem dis- posed to break, as the object of prescribing an emetic is merely to burst the abscess, the sulphate of zinc is to be preferred to any other substance. The dose of the sulphate to produce full vomiting is from 7}i to 5«s. If an overdose have been taken, the best antidotes are cretaceous mixtures, milk, and albumen, after the use of the stomach pump. 3. Salts of copper. Both sulphate and acetate of copper operate as powerfuI direct emetics. They have been employed in the incipient stage of phthisis ; and it is a curious tact that in this dis- ease the sulphate will sometimes lie in the stomach for upwards of half an hour without producing vomiting, and then operate at once, and as forci- bly as when it acte in the usual manner. We 3a nervous sympathy, and to call into action the muscles necessary to establish the act of vomiting, may be regarded as an indirect emetic. Thus the mechanical irritation of the uvula and velum of the palate with a feather or with the finger; the motion of a carriage, swinging, whirling, sailing, and many narcotics, produce nausea and vomiting; and the same effects result from inhaling some gases. Among the organic substances which operate as indirect emetics are some varieties of acrid oil, in combination with resin and other principles, as found in the cotyledons of sinapis nigra, the flow- ers of anthemis nobilis, and the leaves of asarum Europxum. 1. Mustard. A table-spoonful of flour of mus- tard mixed in water forms a ready and useful emetic, in cases which admit of stimulants : it operates quickly, and with less nausea than tho direct emetics. This dose is rather large if the flour of mustard be genuine ; but that usually sold in the shops contains, according to Dr. Paris, one-sixth part only of genuine mustard. Emetics of flour of mustard are useful in cases of intoxi- cation threatening apoplexy, as the stimulant pro- 782 EMETICS. perty of the mustard proves beneficial after its emetic operation is over. In the atonic form of gout, also, in which no irritation is more hurtful than that arising from crude undigested matters in the stomach, a mustard emetic may prove highly beneficial, or at least the substance employed to excite vomiting, in such a case, should be of a warm stimulant kind, the operation of which is not followed by debility. For the same reason, no emetic is so well suited for cases of malignant cholera as mustard. 2. Camomile Flowers. A strong tepid infusion of these flowers is powerfully emetic, when ad- ministered in doses of from f.^iii to f.^iv ; and a weaker infusion is well adapted for promoting the action of other emetics, when the stomach is weak and likely to be oppressed by the use of tepid water. 2. Asarabaca. This plant owes its emetic pro- perty to a combination of acrid oil and cytissina.* It is very seldom employed, as it loses much of its emetic power by drying and keeping. 4. Emetina [Emetia]. A more common indi- rect emetic than either of the three substances already mentioned is emetina, as contained in the roots of ipecacuanha, (cephaelis ipecacuanha.-)-) This principle operates more quickly as an emetic than the root which yields it, and ita action is fol- lowed by sweating and a tendency to sleep. It has not been much employed in this country, but the French physicians prefer it to ipecacuanha. It is ordered in a solution of four or five grains in six fluidounces of water, of which two fluidounces are ordered to be taken every half hour until full vomiting is procured. That it operates on the nerves through the medium of absorption has been demonstrated by injecting a minute portion of it into the jugular veins, the cavity of the pleura, the tissue of the muscles, and the anus of a dog; in all of which modes of applying it, vomiting is produced. If it be over-dosed, danger- ous, sometimes fatal effects ensue: when the latter occur, it excites inflammation of the mucous membrane of the alimentary canal, and the lungs are found gorged with blood, and approaching to hepatization. The best antidote is infusion of * This peculiar principle received its name from having been first obtained from the seeds of the cytissus labur- num by MM. Chevallier and Lassaigne. In a separate Ft.ite it is of a yellow colour, has a nauseous bitter taste, attracts moisture from the air, dissolves readily in water, hss so in alcohol, and is totally insoluble in ether. It is better known from its negative than its positive quali- fies, as none of the re-agents which usually precipitate bitter vegetable infusions make the least change in it; nor does it display either acid or alkaline properties. t Emetina is procured from ipecacuanha by treating the powdered root with cold distilled water until it ueases to take up any more soluble matter. This watery infusion is then to be concentrated by evaporation in a water bath ; subcarbonate of magnesia added to it in excess, and the evaporation continues to dryness : after which it is to be treated with strong alcohol, and the extract thus procured again treated with water, ami eva- porated to dryness. In its pure state emetina is white, pulverulent, unalterable in the a'ir, scarcely soluble in cold water, soluble in hot water and in alcohol, but not in ether. Its taste is slightly bitter, and it displays alka- line properties. It is usually, however, procured in the f>rm of brown scales, semi-transparent, with an odour resembling raromel, and a bitter, slightly acrid taste. It is a compound of carbon, hydrogen, oxygen, and nitro- gen. Gallic acid, and infusion or tincture of galls pre- cipitate from its solutions in an insoluble form; and it is also thrown down by tincture of iodine, subacetate of lead, bichloride of mercury, and muriate of tin. When it is separated from the ipecacuanha, what remains is inert. It was discovered by M. Pelletier in 1817. galls, which, by forming an insoluble precipitate with the emetina, neutralizes and renders it inert. 5. Ipecacuanha root, radix cephaelis ipecacu- anha, which owes its emetic properties to the principle just described, has been known in Europe as an emetic since the middle of the seventeenth century.i It is administered in the form of powder, infusion in water, and solution in wine. The powder is the cortical part of the root, the central or ligneous part being inert: it should be of a bright grey colour, have a nauseating dis- agreeable odour, and a bitter acrid taste which remains in the throat.^ In doses of from Qi to gss it produces full vomiting. If ,^ss of the pow- der be triturated with f.^vi of water, and f.gii of the solution administered at the distance of half an hour, full vomiting generally follows the second dose. The vinous infusion is chiefly ordered for children in doses of f.^ii, repeated every fifteen minutes until vomiting be produced. When ipecacuanha in any form is taken into the stomach, its first effect is on the mucous membrane, as a local irritant: it is, however, partially digested in the stomach, and the emetina thus separated is absorbed and produces that simultaneous action of the muscles of the abdo- men, the thorax, and the diaphragm, which con- stitutes vomiting. But, sometimes, in the largest doses, it fails to produce this effect; a circum- stance, which, if the drug be genuine, can only be attributed to idiosyncrasy. In administering ipecacuanha, or its active principle, as an emetic, it may be given with the intention of either sim- ply unloading the stomach, or of acting sympa- thetically on more distant organs after it has per- formed its emetic effect. When prescribed with the first intention, it frequently operates also on the bowels, owing to some of it being forced be- yond the pylorus in the first effort of vomiting; and on this account, when added to jalap, the purgative properties of this drug are much aug- mented. When it is desirable to extend its ac- tion after vomiting, this part of its operation should be less aided with tepid water than when vomit- ing only is required ; the result is a powerful de- termination to the surface and copious perspira- tion, from the continuation of nausea after its emetic effect has ceased. The question has fre- quently been discussed, whether ipecacuanha and tartar-emetic may be indifferently employed as an emetic ? The answer is not difficult. In choos- ing between these emetic substances, we must be guided by the condition of the system, and the nature of the disease, as well as the intention for which the emetic is prescribed. In intermittents, if the frame of the patient be delicate, ipecacuanha is to be preferred ; if it be robust, capable of bear- ing full vomiting with impunity, and without suf- fering from the subsequent debilitating effects of profuse sweating, the antimonial preparations will be found most useful. In continued fever, in se- lecting an emetic we must not only prefer that which will produce full vomiting, but which will excite also that state of the surface which may J The name of the root is a compound of two Peru- vian words, ipe signifying root, and Cuanha the name of the place where it was first found. $ Owing to a peculiar idiosyncrasy, some persons are affected with severe dyspnoea by the odour of ipecacu- anha. (See Asthma.) EMETICS. 783 fts a crisis; consequently the tartrate of anti- ' cle is the real active principle of squill. Squill is rp, J *n" potassa is preferable to ipecacuanha. '. seldom employed as an emetic ; but in cases ha hH ence °* nause>» in checking hemorrhages ! where its emetic influence is no objection and en well established; but the superiority of j does not interfere with its expectorant powers, as V cuanha over all other emetics in those con- j in hooping-cough, croup, and some other pulmo- hl' h Mi. uter.Us' nas on'y lately been esta- j nary diseases, it is found useful. When emetics lsuecl by the experiments of M. Caffin, (Journal I are thought to be serviceable in ascites and ana- fDir decine'voL lxif.) and Dr. Osborne, sarca, squill has been supposed to be particularly o u lin. (Observ. on the Employment of I indicated, but it is in no respect superior to tartar- Ipecac, in Menorrhagia.) The latter found that in doses of a scruple taken in the evening, and fol- lowed by an acidulated saline purgative next morn- ing, the discharge in menorrhagia ceased in twen- ty-four hours; and when it returned after a short interval, the repetition, once or twice, of the ipe- cacuanha emetic never failed to render the cure permanent. Dr. Osborne's experiments were con- ducted in Sir P. Dun's Hospital : in several of the numerous cases treated in this manner, the ipeca- cuanha arrested the discharge after tartar-emetic had produced no beneficial effect: and its influ- ence was not modified either by a full pulse, with much excitement, or in a greatly weakened state of the system. In dysentery the superiority of ipecacuanha, when full vomiting is required, was determined by a set of experiments made by Sir George Baker. (Trans, of the Royal College of Physicians of London, vol. ii.) Finally, ipeca- cuanha is preferable in every instance in which the powers of the stomach require to be main- tained, and yet vomiting is requisite ; and in cases in which a chronic diarrhcea exists, there can be one opinion only as to its superiority over tartar- emetic. Although the usual dose of ipecacuanha is from ^i to gss, to promote full vomiting, yet this must vary considerably in reference to sex and tempe- rament. The dose for a young infant is gr. i; for a child of from six to ten years of age, grs. x; and for the youth of either sex under twenty, from gr. xiv. to 9'- With respect to the propriety of substituting emetina for ipecacuanha, some advantages might result from doing so; its effects, as an emetic for instance, are more certain, and its use is generally followed by sweating and a tendency to sleep. The dose of the emetina is small, not exceeding gr. v. for an adult; and as it is very soluble in water, it can be more readily administered in divided doses than ipecacuanha. Besides, the powder of ipecacuanha loses much of its activity when kept for many months, whereas emetina is not at all altered by keeping. 6. Squill, scilla maritima.—The bulb of the squill, when properly dried, possesses considerable emetic powers, which are said to be attributable to a peculiar principle named scillitina ,-* but this is a compound substance, containing, besides the active principle of the squill, sugar, and traces of citrate of lime. Ether, when digested on squill, and evaporated afterwards on water, leaves on the surface a thin pellicle, intensely bitter, whilst a soluble matter mingles with the water : this pelli- * Scillitina was first obtained from the sciuill by Vogel. When pure it is colourless, intensely bitter, with some sweetness, friable, and resembles a resin in its appear- ance and fracture, and is equally soluble in water, alcohol, and vinegar. It is deliquescent, gives viscosity to water; but differs from gum in not affording mucic acid when it is treated with nitric acid. emetic in such cases. It is given in the form of powder, in doses of from grs. iii. to gr. xii; or, in that of tincture, from m.xxx. to f.Jji, repeated at intervals. When overdosed it operates as a nar- cotic-acrid poison, causing violent vomitings, diar- rhoea, tormina, bloody urine, tetanus, and a cuti- cular eruption resembling uticaria : in some habits these effects result even after a small dose of the medicine. 7. Tobacco, folia nicotians tabaci, displays powerful emetic properties, whether it be taken into the stomach, inserted into the rectum, or ap- plied to the surface of the body ; but its operation is too difficult to control to permit it to be pre- scribed, under any circumstances, as an emetic. It is mentioned merely because it has lately been recommended as a remedy in dropsy. In the event of its use producing poisonous effects, it is propel to know that infusion or tincture of galls renders the infusion of tobacco inert, and consequently should be instantly administered. Inorganic emetics. — The first of these neces- sary to be noticed, is the tartrate of antimony and potassa, a salt which has been employed as an emetic since 1631.1 As an emetic, it operates through the medium of the nerves, and probably never until it reaches the circulation. It proves emetic, or purgative, or sudorific, according to the frequency of the dose : thus a grain, dissolved in a moderate quantity of water, given every ten or fifteen minutes, produces full vomiting; tbe same quantity repeated every three hours may vomit once, but it afterwards purges ; and if administer- ed once in six hours only, it causes copious dia- phoresis. It is the best of the emetic substances for producing full vomiting at the commencement of continued fevers, and in all cases where it is of advantage to keep up a state of nausea. In mania it is preferable to all other emetics ; but it requires to be prescribed in much larger doses than in most other diseases, a scruple often producing little effect whilst the state of congestion of the brain remains; but if the lancet have been previously resorted to, a grain or two grains will produce full vomiting. In melancholia the direct emetics are to be preferred, as the nausea which follows the use of tartar emetic is in this instance inju- rious, by augmenting the collapse which always occurs in this disease. When overdosed, besides operating as a power- ful emetic, tartar-emetic produces poisonous effects on the mucous coat of the alimentary canal. The best antidotes are infusions of yellow cinchona bark, galls, catechu, or any of the astringent vege- tables, the tannin of which unites with the oxide of antimony, and forms an insoluble inert salt. But it is not easy to determine what is an over- •f It was discovered prior to the above date, but was first made known by Adrian Mynsicht, in his treatise entitled, Thesaurus Medico-Chemicus. 7S4 EMMENAGOGUES. dose of this salt in disease. The custom of pre- scribing it in large doses has lately been revived by Rasori and oilier Italians, and their example has been much followed by all the continental physicians. L.ieiinec states that he gave it to the extent of forty-eight grains, in tlivided doses, in twenty-four hours, without any deleterious effect, and even witnout exciting vomiting, except on the first day. Dr. Christie, in a treatise on the nature and treatment of cholera, asserts that he has given J)i at once, with the effect only of pro- ducing some vomiting and a few watery stools. The writer of this article, who has frequently prescribed it in doses of grs. iii, repeated every third hour, has observed that it seldom causes vomiting after the second or third dose. Rasori explains the power of sustaining such large doses, on the principle that a peculiar diathesis accom- panies diseases of excitement, in which only such doses can be borne; and that it ceases as recovery takes place. Laennec, however, says that this power of endurance does not cease at the close of the fever, although it is diminished ; a circum- stance which, if the observation be correct, may be ascribed to the force of habit. When tartar emetic proves poisonous, the symp- toms resemble those of cholera; violent vomiting, diarrhoea, great pain and tension of the abdomen, and delirium ; convulsions supervene, and death sometimes results. These symptoms have some- times followed the administration of moderate doses. On examination of the body after death, the only marks of previous excitement are slight congestion in the brain, and a thickened state of the villous co it of the stomach and the duodenum, which is covered with a tough mucus. Tartar emetic is administered in substance, in solution in water, and in solution in wine. The latter preparation is an objectionable one ; the free tartaric acid of' the wine converting the potassa into a bitartrate, and thus decomposing the triple salt; and the solution should always be made at the time it is to be taken. The solution in wine is chiefly employed in the diseases of children. Some practitioners still adhere to the opinion of Sydenham, who reprobates the use of antimonial emetics for children under eight years of age; but we have never seen any disadvantage follow their administration to children of two or three years of age; nor even, when judiciously employed, to in- fants at the breast. * m rp..... A. 1. I HOMSON. EMMENAGOGUES, (from lutfvia, the men- ses, and t'yt, to induce,) are medicines which promote the menstrual discharge, ft has been doubted whether any medicines operate directly upon the uterus; the decided influence of some in promoting its periodical discharge being referred to the diseased organ sharing in the salutary effect of such medicines on the general system. To de- termine fairly the correctness of this opinion, we must take into consideration the nature of the or- gan and its function in the unimpregnated state. The texture of the uterus is fibrous, dense, compact, and abounding in blood-vessels; the veins are destitute of valves : it is also well sup- plied with nerves, and with lymphatics on its ex- ternal surface. Internally it is lined with a soft, delicate, spongy membrane, composed chiefly of capillary vessels. Such is the organ :—what t* its function in the unimprognated state ? How far is it adapted to perform the functions of a se- creting oriian 1 Is the periodical evacuation de- rived from it a true secretion, or a mere discharge from vessels oppressed by a local plethora ? In reply to the first query, it is scarcely neces- sary to say that its function is menstruation ; a discharge periodically recurring once a month. The second and third queries involve a matter of controversy ; but the prevailing opinion is in fa- vour of the capacity of the uterus to secrete; and, consequently, that the discharge which it exudes is a real secretion. There is nothing in the ana- tomical structure of the uterus that unfits it for the function of secretion; and were any argu- ments necessary to refute the notion that menstru- ation depends on a general plethoric orgasm, it would be only necessary to bring forward the cu- rious facts bearing on this point presented by the Hungarian twin sisters. These two females were united at the lower part of the back, and lived to the age of twenty-two. The same blood flowed in the vessels of each,—for the abdominal vessels were found, after death, united at the loins; yet the uterine function was distinct in both; it dif- fered in its period, and also in the quantity of the discharge. Indeed, in reflecting on the nature of the organ itself, on its resemblance to other glan- dular organs in the manner in which it is supplied with blood, and on the adaptation of its internal surface to exhalation, we can have little hesitation in admitting that the manner in which the peri- odical discharge is supplied closely resembles that of a secreted fluid. The uterine arteries are not only exceedingly convoluted, but they are larger and have thinner coats than the veins, in the un- impregnated state : the blood is, therefore, brought into the organ readily and in considerable quan- tity, whilst it is slowly returned from it,—a state of vessels highly favourable to the secreting func- tion. It is true that, previously to menstruation taking place, there are symptoms indicative of general plethora as well as of local congestion; yet this fact only proves that the discharge is con- nected with such a state of the system ; not that it is caused by this state, nor that the relief which follows is attributable to blood being discharged by the uterine vessels. The admission, also, that there is an increased determination of blood to the organ at the period of menstruation, does not mil- itate against the opinion that the discharge is a secretion ; since it is well known that every glan- dular organ, when excited by its appropriate stim- ulus, becomes a centre, as it were, to which the blood is directed. Again, if this discharge were merely the effect of a local plethora, it would be blood, which is not the fact; for it does not coag- ulate like blood, nor does it contain fibrine. If it be thus evident from reasoning, that menstruation is not the mechanical result of a local congestion, let us examine how far observation supports the fact that it is a secretion. The uterus, as we have already stated, resem- bles a gland in its vascular supply ; and this re- semblance extends to its diseases; an inflamma- tory state existing in it being often followed by scirrhus and cancer. Like other secreting organs, also, its function is often imperfectly performed EMMENAGOGUES. 7So and the secretion, therefore, is liable to vitiation ana derangement In the first efforts of the or- gan the secretion is usually thin, colourless, de- tective, in quantity, and its recurrence irregular and protracted: when it is suppressed, it cannot ne restored by inducing plethora; nor can the now, when it has commenced, be checked by ve- nesection or any other means of depletion. In making this remark we must not be misunder- stood : it is not our intention to assert that inor- dinate evacuations in other parts of the system do not influence the uterine discharge ; on the contrary, we are perfectly aware that preternatu- ral evacuations induced in the other organic sys- tems will suspend the course of the catamenia, on the same principle that increased action of the intestinal system suspends the action of the cuta- neous exhalents, and vice versa, sweating checks diarrhcea. Any argument founded on the suppo- sition that the. structure of the uterus is not suffi- ciently glandular for a secreting organ must fall to the ground, when we reflect that the gastric juice is secreted by the stomach, an organ still less glandular than the uterus. We shall only add, that the correctness of the opinion that the catamenia are a secretion, does not depend alto- gether on circumstances connected with the organ itself; experience having ascertained that this dis- charge is intimately connected with the state of the ovaries; for when these organs are much dis- eased, or removed, or altogether absent, no men- struation occurs. It is not necessary to the estab- lishment of the truth of our opinion that we should be able to explain the cause of the period- ical return of the catamenia. If menstruation depend, as we believe it does, on the secretory function of the uterus, it is obvi- ous that in the unimpregnated state it ought al- ways to happen at its regnlar period when the organ is in a natural or healthy state ; and that in order to promote its return, when it is inter- rupted or suspended, such medicines must be em- ployed as will tend to restore the oreran to that precise state or condition on which the exercise of this function depends; and it is to these that the appellation Emmenagogue can only be pro- perly applied. They may be such as will act either immediately on the uterus itself, or such as will merely influence that organ as a part of the general system; emmenagogues, therefore, may be arranged under two heads—direct and indirect. We shall be able to understand the manner in which both operate, and the propriety of employ- ing the one or the other, only by having a clear idea of the nature of the morbid condition of the organ, and whether the obstruction or interruption of the periodical discharge depend on a diseased state of tl'ie uterus itself, or is the effect of the pre- sence of other diseases in the system. In some instances the suppression of menstrua- tion is a primary affection, " often," as Dr. Den- man has justly remarked, " although not univer- sally, succeeded by a certain train of untoward symptoms;" but more frequently it is the result of other diseases ; and, therefore, the nature of these, as well as the state of the patient with re- spect to vigour and constitution of body, must de- termine the kind of remedial agents to be selected as emmenagogues. Thus when the delay of the Vol. I.—99 3n.* regular appearance of the discharge, after it has once appeared, occurs in females with a pale or leucophlegmatic countenance, indicating an atony of the vital powers, stimulant and tonic medicines are required, to give to the vascular system th-.t degree of power which is necessary to maintain the healthy action of the capillaries : on the con- trary, when the complexion is florid, when there is much tension of the system, or when the sup- pression is connected with great irritation of the uterine system, it is easy to understand that men- struation is more likely to be aided by vv hatevei can diminish excitement and soothe and calm irritation than by stimulants. Thence the fact, that very different, nay very opposite remedies are required to remove_ amenorrhoea, in different instances. Stimulants, whether corporeal or mental, un- doubtedly tend to an early development of the uterine organs, and consequently to the appeai- ance of menstruation sooner than is usual : thus in tropical climates, and in those females who in- dulge in luxurious and pampered habits, the age of puberty is earlier than in those who inhabit the temperate and frigid zones, and whose habits and passions are better regulated. The continued in- fluence of stimulants is said, also, to prolong men- struation beyond the period of life at which it usually ceases; but this is at least problematical. All emmenagogues are more or less stimulants; and in cases in which a stimulant influence is contra-indicated, they cannot be employed until the excitement be reduced, and can then be only employed under certain restrictions. When the uterine obstruction or irregularity is accompanied with a pale complexion and a lan- guid state of the system, a variety of medicines are prescribed, either with a view of directly in- fluencing the uterus by some specific action, or of invigorating the habit, and thence eventually promoting its secretory function. By the indis- creet use of the former, much injury may be done to the organ itself: on the latter, however judi- ciously prescribed, we cannot always depend; they may improve greatly the general health, and yet the catamenia may not reappear. It ought also to be well understood that idiosyncrasy, natural conformation, diseased states of the uterus itself, or of the ovaries, often are obstacles effectually opposed to the salutary influence of emmenagogues. As we have already mentioned, it has been doubted whether there is any medicinal agent which, when taken into the stomach, exerts a direct stimulant influence on the uterus : but if we admit that some substances find their way to particular or- gans,—for instance, nitre to the kidneys,—there is no reason why such should not be the case with regard to the uterus; experience, however, has not yet demonstrated that this is the case. But a stimulant effect may be propagated from neighbouring parts to the uterine vessels: thence some cathartics, which operate chiefly upon the rectum, influence the uterus. When the obstruction is accompanied with a florid complexion, and " the colour of the cheeks is the flush, of disease, not the glow of health," I (Denman,) before taking into consideration the ! uterine function, bleeding and other antiphlogistic means of treatment must be resorted to ; and until 786 EMMENAGOGUES. the $r»>neral excitement be subdued, the employ- ment of emmenagogues would be injurious. It is also questionable, whether, even after this has been accomplished, any of the substances supposed to act directly on the uterus should be employed ; but if they may be administered, they will be most likely to prove beneficial when given imme- diately after the reduction of the febrile excitement. The employment of emmenagogues is not con- fined to cases of simple obstruction or suppression. In some females the pain with which menstruation is accomplished embitters much of life. Some of the substances employed as emmenagogues are supposed directly to lessen uterine irritation ; and thence they are closely allied with sedatives and antispasmodics. I. Direct Emmenagogues.—These may be divided into immediate and mediate. 1. The only immediate emmenagogue is elec- tricity. It is well known that when this power- ful agent is passed through any part of the body, a painful sensation is felt at the point of commu- nication. Thus, if the knob of a discharging rod, connected with a chain communicating with the outside of a charged Leyden jar, be applied to one side of the pelvis, and the knob of the jar itself be applied to the side, a feeling will be instantly pro- duced, as if a small sword was thrust through the part, and a stimulant impulse is given to the ute- rus, by the direct passage of the electrical fluid through it. The stimulant influence of a shock thus communicated, is obvious by the sensation which it excites; but it equally takes place, though in less degree, when no sensation is produced, as when a continued current of the fluid is passed through the organ, by making it a part of a cir- cuit communicating with the prime conductor of an electrical machine. The direct application of electricity is admissible only when a torpor of the uterus exists, indicated by a suppression of the catamenia with a pale complexion and a languid state of the circulation. But even in this state of the habit and the organ, it must be remembered that, whilst applied in moderation, this agent rouses the activity of torpid parts, in large quan- tity it injures materially, if it do not destroy alto- gether the excitability of this organ. In employ- ing electricity, therefore, as an emmenagogue, it should be first used under the form of accumulated electricity, or the bath as it is termed, then the aura, and, lastly, shocks should he given. At first, the shock should be moderate ; as, in nervous ha- bits, syncope has followed the unguarded commu- nication of powerful shocks ; but with ordinary caution in its application, electricity has been found a powerful agent in amenorrhoea, depending either on general debility of the system or atony of the uterus itselfT (See Elf.ctricity.) The influence of ergot of rye, secale cornufum, on the impregnated uterus, at the period of parturition, has led to the belief that it may be employed as a direct einmenagoguc. Admitting that ergot acts directly upon the uterus, it cannot be denied that ite influence in parturition is opposed to that which is requisite for exciting the uterine discharge. If menstruation be a secretory action, a certain supply of blood is requisite for its performance ; but ergot acting on the motor nerves, and causing muscular contraction, would necessarily lessen this supply, and produce a state of parts more calculated to impede than to forward the menstrual discharge. Experience his also demonstrated that ergot has indeed very slender pretensions to the character of an emmenagogue. 2. The mediate direct emmenagogues compre- hend both organic and inorganic substances. Among the former, madder, the root of the rubia tinctorum, has been long employed and relied upon, without any accurate idea of the manner in which it operates ; although, from its tinging the urine and the bones of a red colour, it has been supposed that, as it passes into the circulation, it finds its way to the uterus, and directly influences that organ. The late Dr. Barton, an American physician of eminence, placed great reliance on its deobstruent powers; and it was also much esteemed by the late Dr. Home, of Edinburgh, who, in his clinical experiments and histories, has recorded his decided opinion of its efficacy as an emmenagogue. He gave it in doses of from Jjss to J5'» twice or three times a day. But notwith- standing these authorities, madder is an equivocal emmenagogue, and is now rarely or never employed. Savine, the leaves and herbaceous part of the juniperus sabina, which owes its stimulant pro- perties to a volatile oil having some affinity to that of turpentine, is an energetic emmenagogue ; and from its proneness to produce uterine hemorrhage, and cause abortion, there is some reason for the opinion that the volatile oil is taken into the cir- culation and acts directly upon the uterus, on which it exerts' a stimulant influence. More than a century ago, its tendency to produce abortion led to its employment as an emmenagogue; but from an opinion expressed by Dr. Cullen, it fell into disrepute. In whatever manner it acts, savine, or its oil, is well adapted for cases of amenorrhoea connected with a feeble stale of the constitution, and a languid circulation. The dose of the pow- der is from gr. v. to gr. x.; that of the oil, which can be readily formed into an oleo-saccharum, from m.ii. to m.vi. The extract, ordered bv the Dublin Pharmacopoeia, is a useless preparation; the volatile oil being dissipated by the heat neces- sary to be used in forming the extract. Seneka root, the root of the polygala senega, is esteemed a useful and active emmenagogue by the American physicians. The active principle, which is supposed to be a peculiar salt, first noticed by Peschier, and named by him polygaline or poly- galina,* resides in the bark of the root. Dr. Hartshorne, of Philadelphia, who first empl >v ed it as an emmenagogue, found that it was most use- ful in recent cases of amenorrhcra. He began its use two weeks previous to the expected appearance of the catamenia, giving it in the form of a satu- rated decoction, to the extent of a pint in twenty- four hours, pushing the dose as far as the stomach would permit, until the discharge appeared. Dr. Chapman, of Pennsylvania, adds his testimony to that of Dr. Hartshome in favour of senega mot and believes that it exerts a specific acti >n on the uterus ; but it ought to be mentioned that the patient is directed to be prepared by an alterative course of calomel, carried to gentle ptyalism ; on * Peschier procured gr. 100 of this salt from (5 ounces of the root. Me asserts that it is united with a peculiar acid, which he lias called pulygaliaic. EMMENAGOGUES. duet> ,h m U 1S difficuU t0 8ay h™ "inch is If howl meurCUnal' h0W much to lhe "«ega. nnvrictan?!: lHe °b8ervations of *e American aTtention of V^T1' P°'yga,a *"«« merits the attention of British practitioners as an emmena- ,J?°rricineS Perhaps merit "-ore the appella- tion of d,Mct mediate emmenagogues than the preparations of mercury. They effect almost a specific change upon the whole glandular system; and, consequently, if the glandular nature of the uterine function be admitted, it is easy to conceive that they are likely to affect the capillaries in the uterus, when these are in an unnatural or morbid condition. The preparation best suited for em- menagogue purposes is calomel; it is mild in its operation, and at the same time certain in its influence on the general system. In the combina- tion in which it exists in Plummer's pill in par- ticular, it has been found highly beneficial, the precipitated sulphuret of antimony greatly aiding its power. In this combination, it may be given in doses of from five to twelve grains every night and morning, until the gums be sensibly affected. From what has been said, it is obvious that electricity is the only direct emmenagogue, and that the idea of the others acting upon the uterus itself is rather interred than certain. It is never- theless true, that, in whatever manner they act, they stimulate the uterus; and, therefore, some caution is requisite to be observed in their adminis- tration. Thus we must be certain that the sup- pression is not connected with pregnancy ; and even when this is not the case, there is some diffi- culty in deciding upon the propriety of adminis- tering direct and stimulant emmenagogues ; the uterus may be in such a state of active disease, as to render their influence upon it extremely hazardous. II. Indirect Knimenagogues* The opera- tion of these is effected in three ways: 1. By the substance operating on the kidneys or the intestinal canal, and stimulating the uterus by proximity. 2. By the substance acting on the stomach and improving the general health, so that the uterus shares the general salutary influence. 3. The uterus may be' specifically acted upon through the medium of the nervous system. The substances that operate in the first manner are, some diuretics, and those cathartics which especially stimulate the rectum. The diuretics are such as pass to the kidneys undecomposed, and powerfully stimulate these organs : thus nitre administered in doses of from ^i to gi, in any bland fluid, possesses decided emmenagogue pow- ers. Foxglove operates in the same manner. Among the emmenagogue cathartics, aloes holds the first rank. Its influence can only lie referred to its action on the rectum, and its extension to the uierus, producing a state of the organ closely allied to that which is the result of the application of a direct stimulus to it. The powerful sympa- thetic influence of aloetics is well illustrated by the effect which sometimes follows their adminis- tration after the total cessation of the catamenia. For a certain period after this event takes place, the uterus retains tho disposition to take on that state of vascular action which determines the peri- 76f7 odical discharge; but it is incapable by its natural efforts to effect the discharge. In this state of uterine susceptibility, the excitement of the rectum by an aloetic purgative almost invariably induces the return of the menses in a slight degree, pro- vided the cathartic be given at the period when the discharge had previously been accustomed to appear. Now if a purgative produce so powerful a sympathetic action when this uterine function has ceased to be any longer essential, we can rea- dily imagine that a more powerful effect is likely to be the result of a similar extension of action from the rectum to the uterus at a period of life when the susceptibility to uterine impressions ex- ists in a high degree. Experience has sufficiently demonstrated that such an extension of action really occurs. In prescribing aloes, however, as an emmenagogue, the cause of the suppression must be kept in view ; for this medicine cannot be safely administered in an irritable state of the uterus. To secure its influence on the uterus, it is supposed necessary to administer the medicine in a solid form; but we are of opinion that this supposition is founded on a mistaken idea of its mode of acting; we have seen it most successful when it has been prescribed in conjunction with alkalies, which greatly aid its solubility. The administration of a pill containing one grain of calomel, the same quantity of powder of digitalis, and three of extract of conium, at bed-time, fol- lowed in the morning, by half an ounce of wine of aloes and myrrh, in conjunction with the min- eral alkalies and ammonia, (See London Dispen- satory, sixth edit. p. 941,) for two or three days previous to the expected return of the menstrual discharge, have, in our hands, proved generally successful. We are usually advised to avoid re- commending the use of aloetics to persons subject to hemorrhoids; but although they operate chiefly on the large intestines, the idea that they produce hemorrhoids, or even rouse them to activity in those affected by them, unless the dose be very large, is doubtful. Black hellebore, radix hellcbori nigri, is anothei useful emmenagogue purgative of this class, adapt- ed to plethoric habits: it probably acts by reducing that state of the system which is as adverse to the secretory action of every glandular organ as to that of the uterus. Mead pronounced a high eu- logy on the emmenagogue properties of black hellebore; and it continued to be much employed until doubts of its efficacy were raised by Cullen and Heberden,* after which it fell into disrepute ; but it is still much prescribed on the continent of Europe and in the United States of America. Dr. Chapman thus expresses himself regarding it: " It is especially useful when it purges, in painful menstruation, attended with torpor and constipa- tion of lhe bowels, and perhaps with some degree of insensibility in the uterus itself." (Materia Medica.) From the violence of its action as a purgative, black hellebore requires to be adminis- tered with caution. If it be employed, the tinc- ture is the best form of preparation; it may be added to any purgative, and thus aid in stimulat- * Radix hellebori nigri facultatem movendi menstrua sibi vimlicavit. quam I amen nullo satis firmo argiimeuto usus nnhi coniirmavit.—Commentani dt Morb. hut. et Cur. p. i!01. 738 EMMENAGOGUES. ing the uterus with less risk than is likely to at- tend the use of the root in substance or its infu- sion. The extract of the Edinburgh Pharmaco- poeia, in doses of from gr. iv. to gr. x., combined with extract of conium, has been found useful in the amenorrhoea of chlorotic girls. The same re- marks apply to camboge. Serpentaria, valerian, and wormwood, have been employed, in various combinations, to produce emmenagogue effects, and seem to operate chiefly as stimulant antispas- modics. As such, the preparation of valerian, particularly the ammoniated tincture, is indicated in hysterical habits, when the circulation is in a languid state, and the menstrual discharge ushered in with an hysterical paroxysm : it seems to act chiefly by soothing the nervous turbulence; and may be given in doses of from f.^i to f/jii, in combination with decoction of aloes. The inorganic substances in this division of emmenagogues are, principally, salts of iron, both natural and artificial. The former, which, as they exist in chalybeate waters, are carbonates or sul- phates, are most beneficial when drunk at the springs ; they raise the pulse in strength, and dis- tribute the blood more equally; and, although the quantity of iron contained in the dose of the water, generally half a pint, be extremely small, yet it operates as a decided stimulant tonic. In plethoric individuals, it is often requisite to bleed and purge before the use of the chalybeate is commenced; and if nausea, pain of the praecor- dia, vomiting, vertigo, or a feeling of general ful- ness be, nevertheless, experienced after the waters have been taken, they should immediately be dis- continued. All the varieties of chalybeate water prove beneficial in amenorrhoea connected with a pale leucophlegmatic habit; their operation is on the secretory system, which they influence in a slow but uniformly progressive manner, imparting tone, nervous energy, and general vigour. When the habit of the patient is sluggish, the pilula aloes cum myrrha may be administered with each dose of the water. The whole quantity of the chaly- beate necessary to be taken in one day should be drunk in divided doses, betwixt each of which brisk walking exercise should be used. The arti- ficial preparations require to be given in much larger doses than those contained in the chaly- beate waters, a circumstance which has not been satisfactorily explained. The most common of the artificial preparations employed in amenorrhoea is the officinal black oxide of iron, the scales from the anvil purified. It is a compound of the prot- oxide and peroxide; the former of which com- bines readily with the acid of the stomach. The dose is from gr. v. to Qi; it may be combined with an" aromatic, and administered two or three times a day. Neither the liquor ferri alkalini, nor the ferrum ammoniatum, are active preparations : perhaps the most energetic of all the artificial chalybeates is the tincture of muriated iron ; and it possesses the advantage of being compatible with many bitter tonic infusions and decoctions; as, for example, those of gentian, quassia, orange- peel, and such like. If the sulphate of iron be preferred, it should always be in the form of the proto-sulphate ; but as this salt is rapidly con- verted into the persulphate when it is kept in the usual manner, it should be preserved in alcohol." In the formation, also, of the mistura ferri com- posite, it would be preferable to add the sulphate of iron in solution to the mixture of myrrh and subcarbonate of potassa at the moment of taking the medicine, than to prepare it as ordered in the London and Dublin Pharmacopoeias. When pre- viously mixed, the carbonate of iron, which is at first formed by the exchange of acids between the salt of iron and the alkaline carbonate, is again rapidly decomposed, and transmuted into an inert peroxide of iron ; whereas, when managed as we propose, the protocarbonate is formed in the sto- mach, and immediately exerts its influence upon it, operating as a powerful and effectual tonic em- menagogue. The dose of the protosulphate proper to mix with f.^iss and of the myrrh and alkaline solution is four grains. Its influence is perceived by the rapid change which it induces on the alvine and renal evacuations; the black colour of the former, and the blue streak when the latter is tested with ferro-cyanate of potassa, demonstrating that the chalybeate has entered the circulation. The mediate indirect emmenagogues, which influence the uterine function by their action on the nervous system, are all organic substances, both animal and vegetable. Their influence is chiefly useful when amenorrhoea accompanies highly irritable habits, and the suppression is con- nected with spasm and hysteria. We are of opinion that much confidence cannot be given to castor or to musk ; galbanum and assafcetida are more useful; but they are to be regarded merely as aids to more powerful indirect emmenagogues. On reviewing what has been said on this sub- ject, it is evident that, with the exception of elec- tricity, there is no method of directly stimulating the uterus on which much confidence can be placed ; for little benefit has hitherto been derived from stimulating injections ; and under these cir- cumstances it may be reasonably questioned whether any medicinal agent can be correctly entitled to the appellation emmenagogue. A. T. Thomson. * Green vitriol consists of 36 parts of protoxide of iron, -f- 40 of sulphuric acid, -j- 63 of water of crystallization, = 139 ; when exposed to the air, oxygen is absorbed, and an insoluble subsulphate produced, which consists of 40 parts of acid, -f- 160 peroxide of iron, = 200. 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