N0I1VN 3NI3I03W JO UVigil IVNOIIVN 1 N I 3 I 0 3 W JO ABVaail IVNOIIVN 3NI3I03W JO A « V I ■ I 1 N0I1VN 3NI3IQ3W JO ABVaail IVNOIIVN 3NI3I03W JO ABVaail IVNOIIVN 3NI3I03W JO AIVDM I 315 unsoundness of... (_ Dunglison... 5 Molluscum.......... Dunglison .... 332 Mortification......... Carswell......332 Narcotics........... A. T. Thomson. 362 Nauseants.......... Dunglison.....376 Nephralgia and Ne- phritis............ Carter........377 Neuralgia........... Elliotson......381 Noli me tangere, or Lu- pus .............. Houghton.....385 Nyctalopia.......... Grant........391 Obesity ............Dr. CEdema............ Ophthalmia.......< Otalgia and Otitis .... Ovaria, Diseases of the Palpitation........< Pancreas, diseases of the Paralysis........... [•Parotitis............ Parturients.......... |»Pellagra, or Pelagra. . . Pemphigus.......... perforation of the Hol- low Viscera........ Pericarditis.......... Peritonitis........ Phlegmasia Dolens .. . Pityriasis........... Plague............. Plethora............ !* Pleurisy............. Plica Polonica....... Pneumonia.......... Pneumothorax...... Porrigo............. Pregnancy and Delivery, I Signs of.......... ^Prognosis........... 'y Prurigo............ L» Pseudo-morbid Appear- ances............. Psoriasis............ Ptyalism, or Salivation Puerperal Diseases.. .. Pulse.............. Purpura............ K PUS................ !» Pyrosis............. >Rape............... Contributors Page Williams......403 Darwall.......411 Jacob.......£413 Dunglison. . . 3 Burne........436 Lee___......442 yey.....£449 Dunglison. .. 5 Carter........454 R.B. Todd...A57 Kerr..........475 Dunglison.....477 Kerr.........477 Corrigan......482 Carswell......487 Hope.........495 Mac Adam. . . ),., Stokes......5 Lee......»---529 Cumin.......538 Brown........540 Barlow.......553 Law.........574 Corrigan.....587 Williams......590 Houghton.....637 A. T. Thomson.653 Montgomery . . . 659 Ask..........699 A. T. Thomson.720 R. B. Todd___723 Cumin.......733 Dunglison.....738 M. Hall.......740 Bostock.......752 Goldie........762 Tweedie.......770 Kerr..........770 Beatty........773 (5) f mrr THE CYCLOPAEDIA PRACTICAL MEDICINE. INFLUENZA. (Epidemic Catarrh.) The disease now commonly known by this name, first given to it by the Italians, was not particularly noticed by physicians before the sixteenth century. Since that period it has many times appeared in Europe and in other quarters of the globe. In- fluenza seems to bear the same relation to ordinary catarrh that epidemic cholera bears to the common or sporadic cholera that occurs every year. Of all epidemic diseases it is the most universal; and the rapidity of its march and extent of its range over land and sea, sometimes in both hemispheres and in different climates, in opposite seasons and in all varieties of weather, among people of all classes, naturally led to the supposition that some extraordinary influence could alone give rise to such a wide-spreading malady. The French call it la grippe, under which name Sauvages first described the epidemic catarrhal fever of the year 1743. To collate the various accounts of any one visi- tation of this epidemic, such, for example, as that of 1775, or of 1782, or of 1803, in order to deduce some general principles respecting its mode of propagation, pathology, or treatment, would oc- cupy a considerable treatise: it must, therefore, be an elaborate task to draw general conclusions from all the records we now possess of this singu- lar disease, and to condense them in a space suitable for a work like the present. Limited by this circumstance, we shall take a brief survey, first, of the most remarkable dates of its appear- ance and progress in the last three centuries ; se- condly, its symptomatology; thirdly, its treat- ment ; fourthly, facts and general inferences rela- tive to the causes of it, such as phenomena of the weather and diseases among brutes : fifthly, its contagious property; and, sixthly, its influence on other diseases, and connection with diarrhoea, dysentery, and cholera. 1. We find no medical description of the epi- demic catarrhal fever before the year 1510. "It was called coccoluche, because the sick wore a cap close over their heads." The symptoms of the disease, as it then occurred, nearly resembled those which it has assumed in later visitations, namely, severe pain over the eyes, sneezing, coryza, heaviness, difficulty of breathing, hoarseness, loss of strength and appetite, fever and harassing cou^h. Schenk says that physicians then looked upon it as a new disease. Its course seems to have been in a north-westerly direction, from Malta to Sicily, Spain, Italy, Germany, France, and Britain ; and Short says that »it attacked at Vol.111___3 b» once, and raged over all Europe, not missing a family, and scarce a person, and that none died except some children. In some it went off with a looseness; in others by sweating. Bleeding and purging did hurt." (Short's Chronol. Hist. of the Weather, &c. vol. i. p. 204 ; and Diet, des Scien. Med. Art. Grippe, p. 351.) In 1557, an epidemic of the same nature pre- vailed in different countries. Fonseca says that in this year it infested Asia, thence came to Con- stantinople, and having spread itself all over Europe, afterwards attacked America, its course being westerly. Mercatus asserts that " before the beginning of autumn 1557, it attacked all parts of Spain at once, so that the greatest part of the population in that kingdom were seized with it almost on the same day." (See Report, by Dr. Glass, in Lettsom's Memoir of Dr. Fothergill, 4to. p. 625.) Riverius has transmitted to us an ac- count of this epidemic. Unlike that of 1510, it was fatal to many: in a small town near Madrid, Mantua Carpentaria, bleeding was said to be so fatal that two thousand patients died after it in September. (Short's Hist. vol. i. p. 223.) At Alkmaer, in Holland, two hundred died of it in October. The catarrhal epidemic fever of 1580 was dis- tinguished by its complication with malignant fever or plague, as related by Forestus and Sen- nertus. (Diet, ut supra.) The latter speaks of its ravages at the end of summer and the begin- ning of autumn all over Europe ; in some parts of which, as in Paris, it was the precursor of the plague. (Webster's Hist, of Epidemics, vol. i. p. 263.) It was in Sicily in June, at Rome in July, in August at Venice and Constantinople, in Sep- tember in Hungary and Germany, in October on all the Baltic coast, in November in Norway, in December in Denmark, Sweden, Poland, and Russia; its course being from E. and S. to W. and N. (Short's Hist. vol. i. p. 282.) Mercatus says that it raged also in Spain, and destroyed not a few. (Dr. Glass, ubi supra.) Grand Cairo lost a prodigious multitude the same year by the plague. It is a remarkable fact, and ought not to escape our notice, that France appears to have j been the only country in Europe affected that year by the plague; and it appears also to have been the first to be visited by the epidemic catarrh, its precursor; so that Bnldutius even dates its origin from France. (Short's Hist. i. 262.) The influenza of 1G58, of which Willis has left us an account, visited Europe and this king- dom suddenly in April, and after excessive heat (17) 18 INFLUENZA. in August was followed by a fatal epidemic fever. (Short's Hist. vol. i. p. 331; and Webster's Hist. 310.) Sydenham and Etmuller have described the epi- demic catarrh of 1675, which began in Germany in September, and in England in October. Malta was afflicted by the plague the same year, from which it remained free till the last severe visitation of this scourge in 1813. The epidemic catarrhal fever which raged during the autumn and winter of 1729, in the space of five months' time visiting almost every part of Europe, was very fatal in many large cities, such as Paris and London. Loew says that in the latter more persons died than at any one time since the plague of 1665, about one thousand being cut off weekly in September. In the beginning of winter it reached France. A few weeks after, it visited the upper part of Italy with great mortality. In February it afflicted Rome and the Rhine. Turin and Milan suffered extremely. It reached Naples in March, and after this disappeared.— (Short, ii. p. 54. Hoffmann, Opera, torn. ii. p. 109.) The influenza of 1732-3 is described in the second volume of the Edinburgh Medical Essays, and by Huxham ; and was so far remarkable that it affected the mucous membrane of the alimentary canal as well as that of the organs of respiration. It spread over all Europe, and appeared also in America. It was first noticed about the middle of November in different parts of Germany. Edin- burgh appears to have been the first place attacked in Britain, viz. on the 17th of December, and it raged at the same time in Switzerland, at Basle. It appeared at London and in Flanders the first week in January; towards the middle of the same month it reached Paris, and Ireland towards the end. Cornwall and Devonshire were visited about the beginning of February; few only were attacked at Plymouth, where Huxham practised, so soon as this: but in March it prevailed on all sides. In February Leghorn was attacked, and near the end of it Naples and Madrid suffered. New England in America was invaded by the distemper about the middle of October, which travelled southward to Barbadoes, Jamaica, Mexico, and Peru, much at the same rate as it had done in Europe. It appears to have been at Paris early in the year. "Ellc se manifesto, dit de Jussieu, a la suite de brouillards fetides, plus epais que les tenebres de I'Egypte." (Edinb. Med. Essays, vol. ii. p. 31. Huxham, de Aere, &c. torn. i. Diet, des Scien Med. art. Grippe.) The epidemic catarrh of 1733 was followed by those of 1741 and 1742; the first described by Hallcr, and the second by Sauvages and Huxham. In 1743, towards the end of April, Huxham says' that it was general in England, and in the spring spread over all Europe under the name of "influ- enza," or « grippe." This epidemic was the ore- cursor of the plague of Messina in Sicily the same year ; and it was more fatal in the southern parts of Europe than in England, though it increased the deaths in London in one week to a thousand. (De Aere, &c. torn. ii. p. 104.) The next remarkable visitation of the influenza was in 1762; and an elegant description of it is given by Sir George Baker, « De Catarrho Epi- demico anni 1762," who records its appearance in London about the 4th of April. Razoux, a physician of Nismes, has given an account of the same disease, which was epidemic in Europe gene- rally in the spring. (Diet. art. Grippe.) It at- tacked Breslau at the end of February; Vienna was visited in March, and Hamburg in April. In Venice it was more fatal than in other places. It spared, however, Paris and the greatest part of France; nor can we find any particular cause for this exemption. Nismes most probably was visited; and Webster says that " Toulon lost one third of its inhabitants by an epidemic in 1761." The influenza of 1762 appeared sooner in London than in any other part of England, namely, the begin- ning of April. It was not observed in Edinburgh and Dublin till May; but in June it was general and severe, according to Sir G. Baker, being seen no where earlier than February nor later than July. It had prevailed in America the preceding year. (Webster's Hist. i. p. 410.) It was not till July that it attacked the British sailors in the Mediterranean. It was immediately followed in London by an epidemic dysentery, which raged till November. While the influenza prevailed, the deaths in London scarcely exceeded the usual number. In Manchester they were even fewer than common ; and at Norwich far more died of it than fell victims to the more severe influenza of 1743. (Baker, de Catarrho, p. 33.) The next epidemic catarrh, in order of time, was that noticed in London and different parts of the nation by Dr. Fothergill and some of his friends in the latter end of the year 1775. It was observed also in France, Holland and Germany, and was supposed to be more fatal in those coun- tries than in Britain. (Lettsom's Memoir of the Life of Fothergill, 4to.; and Med. Obs. and In- quiries, vol. vi.) The influenza of 1782 was general over Eng- land, Scotland, and Ireland, between the months of May and July inclusive. A full account of it is given in the second volume of Memoirs of the London Medical Society, by Dr. R. Hamilton, which is the groundwork of the article «Influ- enza" in the Edinburgh Medical and Surgical Dictionary; an account is also given in the first volume of Medical Communications by Dr. Gray, compiled from papers in the British Museum, which is the basis of a like article in the Cyclo- pedia of Dr. Recs. (See also the third volume of Transactions of the College of Physicians, London.) The influenza of 1782 seems to have pursued a course from the east, not very different from that of the epidemic cholera which is now (1832) dis- playing its ravages in Great Britain and France. t is reported to have broken out in September 1 ' ?tJ° Ahfe become very Se»era' i" Ae crew of the Atlas East Indiaman, whilst that ship was saihng from Malacca to Canton. When the sh.p left Malacca, there was no epidemic dis- ease ln th lace . when .t ^^^ I was f0Und that a he very t.me when , eas if haT °n ib°ard„the Atlas in the ^ina ence £ l^Tl '\ ^T Whh as much ™- ence as it did in London in June 1782, and with embee71S7a8T-tSympt0rn;'. \ °ctober «d Nc? vember 1781 lt appeared in the East Indies, and INFLUENZA. 19 was said to have attacked the British army while it was besieging Negapatam in November 1781. Its progress is stated by Webster, to have been from Siberia and Tartary westward. At Moscow it prevailed in December 1781; at Petersburgh in February 1782; and it was traced to Tobolski. It was in Denmark in the latter end of April. From the shores of the Baltic it spread to Hol- land and the Low Countries, and thence to Eng- land. London was said to be attacked sooner than the west and north; Ireland a few weeks later, and the south of Europe later still; for it prevailed in France in the months of June and July, in Italy in July and August, and in Portu- gal and Spain in August and September ; seldom continuing longer than six weeks in any place.* The influenza of the spring of 1803 afforded an occasion for collecting a great number of no- tices from different parts of the country on the subject of this epidemic. The London Medical Society set a laudable example by proposing a set of queries to its corresponding members in a cir- cular letter; and the sixth volume of "Memoirs" contains reports from nearly sixty practitioners in England, Scotland, and Ireland, as to the date of its first appearance, its symptoms, treatment, &c. in their respective neighbourhoods. Dr. Beddoes also interested himself very zealously on the same occasion, and procured various testimonies from his friends and others, which, to the number of one hundred and twenty-four, are inserted in the ninth and tenth volumes of the " London Medical and Physical Journal." These documents contain a mass of very useful information. This epidemic was observed at Paris and in other parts of France and in Holland some weeks before it appeared in London ; and Dr. Bardsley says " the same length of time was occupied in its progress from the lat- ter city to Manchester." (Med. and Phys. Journ. vol. ix. p. 529.) Its course seemed to be from S. to N. It was in Cork and Dublin before it reached the north of Ireland, immediately after a S. E. wind. An epidemic ophthalmia followed it in France, (Diet, ut supra,) and a severe dysentery, such as had not been known for thirty years, in some parts of the United States, which it visited the same spring. (New York Med. Repos. 2d Hex. vol. ii. p. 141.) It was observed to be epi- demic in Sussex, and some of the counties in the S. W. as early as February; in Shropshire, Not- tinghamshire, &c in March; in Yorkshire and Lancashire in April; and at Sunderland in May. (Mem. of Med. Soc. of London, vol. vi.) It was evident that there was a degree of progressive movement northward, by marking the time when it was at the height in each place; yet many of the accounts above alluded to inform us clearly that sporadic or solitary cases exhibiting the true characters of influenza, occurred in several places long before the disease became established, so as to manifest a universal tendency to that form of complaints over the country, in some cases weeks before it was quite developed. It is worthy of notice that this has been remarkably the case with the epidemic cholera. Dr. Gray observes that, in * Transactions of the College of Phys. vol. iii., and Med. Communications, vol. i. Rees' Cyclopsedia, Art. In- fluenza: and Trotter's Med. Nautica, i. 362. Observa- tions on Dis. of Seamen, by G. Blane, M. D. p. 151. 1782, a complaint, similar to the influenza, was taken notice of in some parts of the kingdom several months before that disorder made its pro- gress through it. (Med. Commun. vol. i. p. 6.) The influenza of last year (1831), though generally mild in its character, was almost uni- versal ; for it would seem to have prevailed in both hemispheres in the same year. Accounts have been received of its appearance in India as well as in the United States of America. (Ameri- can Journ. of Science, &c. vol. xxi. No. 44, p. 407.) In many places it has been the precursor of the epidemic cholera. About a month before the latter disease broke out in Warsaw, it pre- vailed in that city. (Brierre de Boismont sur le Cholera, p. 110.) It also swept over great part of England, Scotland, and Ireland, in the spring and autumn, and preceded the milder visitation of epidemic cholera which many parts of Great Britain experienced the same year. Late in the autumn it attacked Paris, the south of Spain, Gibraltar, and Italy, with more severity than it did the British islands. At Rome it was said to occasion great alarm. It has certainly skipped over many countries of Europe in its march from Poland to France through England, so far as we can judge negatively from the want" of official re- ports ; but, with this exception, it has pursued a course not widely different from that of similar former epidemics, and has proved to be a true herald of the epidemic cholera in many places. [In the epidemic of 1831, according to Most, (art. Influenza, in Encyclop.dergesafnmt. MedU cin. und Chirurg. Praxis, Leip. 1836,) 30,000 people, it was asserted, were suffering at the same time in Berlin; and, at a later period, 45,000 in Paris. Another severe epidemic prevailed in Eu- rope and the United States in 1837 ; and another in 1843. Of the European epidemics of 1831, 1833, and 1837, the two first were less severe, and attacked fewer individuals than the last.] II. The influenza does not seem to have exhi- hibited a greater variety of symptoms, in its dif- ferent visitations, than other epidemics. It has varied a little in town and country, in spring and autumn, at the beginning and end of the epi- demic, in different persons, and according to the particular genus or tendency of the epidemic constitution; but still it has maintained some prominent characteristics of its identity at differ- ent periods. The ordinary course of the disease has been marked by the following symptoms :—it usually commenced with slight chills, amounting sometimes to shiverings, and alternate flushings of heat, with languor and sense of extreme weari- ness : then, soreness over the eyes, or pain in the course of the frontal sinuses : these were quickly followed by frequent sneezing, a copious discharge of lymph or thin clear fluid from the nose and eyes, sometimes so acrid as to excoriate the upper lip ; heat and soreness in the top of the larynx and oesophagus, and along the course of the windpipe, with hoarseness and dry cough ; sense of stricture in the chest and difficulty of breath- ing, sometimes attended with darting pain in the muscles subservient to respiration; weight and anxiety about the praecordia, flying pains in the back, knees, calves of the legs, and various parts of the body; depression of spirits, and sudden 20 INFLUENZA. and extraordinary prostration of strength. The tongue was mostly covered, at an early period of the complaint, with extremely white mucus, like cream—a symptom particularly noticed by Hux- ham, Baker, Pettit, and others : there was loss of appetite, the thirst was inconsiderable, and the pulse generally quick, weak, and soft. The preceding symptoms appeared in various degrees and combinations, as the violence of the disease fell more particularly upon the mucous membrane, in the head, in the throat and chest, or in the stomach and bowels. When the disease chiefly affected the head, vertigo, violent headach, greatly increased by the cough, and delirium, were not unfrequent: there was hemorrhage from the nose, and pain in the ears; from which, in one case, a clear fluid was poured out like that from the nostrils. (Med. Trans, of the College of Physicians, vol. iii. p. 69.) In some rare cases the tonsils and back part of the throat were in- flamed, so that suppuration was the consequence. When the violence of the disease fell upon the lungs, as in old people, asthmatic patients, and those predisposed to phthisis, hemoptoe was not uncommon, and frequent troublesome cough which prevented sleep. It often degenerated into pleu- risy and peripneumony. In common cases the cough became loose in three or four days. The stomach was affected with nausea in many, and vomiting in some ; and a spontaneous diarrhoea relieved both head and lungs, and speedily cut short the complaint. But in many instances, and in several visitations of the epidemic catarrh, a morbid determination to the intestinal canal was manifest from the beginning; which, so far from being considered a salutary effort of nature to ! relieve the system in that way, required especial I care in the treatment, and the utmost caution in the use of purgatives. The fever was generally mild in the day-time, and it increased in the I evening ; and it seldom abated till some critical amendment took place by perspiration or other- j wise. There was little remarkable in the urinary I secretion. The duration of the complaint was I from a day or two to a week or fortnight. In some, the symptoms, after abating in two or three j days, returned and raged with violence. The far greater part had critical sweats about the third day, which, attended with free expectoration, banished the fever on the fifth day. One of the most remarkable features of influenza is the de- ' bility ; so that many could not rise from the hori- zontal posture without sudden faintings, even in the state of convalescence; and the debility often remained for a considerable time. The sudden- ness of the invasion, the pain and tightness in the forehead, with pain in the back, knees, and mus- cles, and singular prostration of strength, were thought to be distinguishing marks between the influenza and common catarrh. Indeed, the pain or soreness in the face, temples, and cheekbones, was considered the most certain pathognomonic symptom in 1782; "and now and then was felt previously to the catarrh, and not unfrequently was followed by very little or no catarrhal affec- tion." In one district in Gloucestershire, a practitioner states that "in no two persons in 1803 did he observe precisely the same symptoms." (Med. and Phys. Journal, vol. x. p. 309.) If this wa, the case, the symptoms might be expected to vary considerably in different places, as well as in d.f. ferent visitations of the distemper. And th.s has happened accordingly. The rarer occurrences were, an unusual disposition to sleep, strangury and bloody urine independent of blisters, peculiar slow and strong pulse, with excess.ye debility, ai at Newark ; ringing in the ears and abscess, and abscess in the frontal sinus; of which last Dr. Rush had three cases in 1790. (Trans, of Col. of Phys. iii. 68, and Rush's Med. Inquir. ii. 354. Mem. of Med. Soc. vol. vi. p. 383.) The duration of influenza in any one place sel- dom has exceeded six weeks. Upon the whole few have died of this complaint, although it has often attacked more than one-half or even three- fourths of a whole community. The chief vie- tims have been the aged and asthmatic, those of tender lungs and of full oppressed habits. Those of middle age were more liable to be affected than old persons and children ; and persons exposed to the air than those who were confined. Many recovered their strength very slowly, and some, especially in 1762, fell into incurable consumption. [Some epidemics have, however, proved ex- tremely fatal. The mortality of the epidemic of 1837 in Europe was greater than that from cholera, although the disease was by no means so severe, or so rapidly fatal. This was owing to its attacking almost every one, whilst the ravages of cholera were comparatively limited. It has been estimated by Dr. Graves (Clinical Lectures) that in Dublin alone, 4,000 persons died of the influ- enza of 1837.] III. One general observation seems to apply to almost every epidemic disease, including even those of a pestilential nature, viz. that during its prevalence numbers are attacked in so slight a manner as to require but little medical care. Hence the influenza, which in all its visitations has had a favourable character in the majority of cases, has been easily removed by mild diluents, rest, and abstinence for a few days from animal food and fermented liquors. Besides this, a com- plaint so various not only in its symptoms but in the degrees of their intensity, modified too at dif- ferent periods by season, climate, and epidemic constitution, would of necessity call for the exer- cise of much discretion in the employment of remedies. But, making due allowance for all this variety of character in the complaint, and for the judicious adaptation of a corresponding treatment, physicians of eminence, in different countries, seem to have agreed remarkably in their testi- mony as to the general rules and principles of their practice; and from the very beginning of the sixteenth century, in their reports, with respect to bloodletting, to the caution about active purga- tives to the employment of a cold regimen, and to the restricted use of opiates, there is a very striking and satisfactory coincidence. In the mild attacks of the disorder, few if any medicines have been required. I„ seVere cases, emetics at the beginning relieved the sufferings ot the head and chest, and, combined with gentle aperients and antimonial or saline medicines, were found useful in mitigating the fever and pro- moting a salutary diaphoresis. INFLUENZA. 21 No observation is to be found more general in practical writers in this disease than that blood- letting could rarely be employed with safety, far lc*s with benefit, on account of the alarming de- bility and weakness of the pulse; and when it was strongly indicated, practitioners were sparing in the quantity of blood, and cautious in repeating the remedy. In the epidemic of 1510, Dr. Short tells us that " bleeding and purging did harm." In 1557, bleeding was said to be so fatal, that in a small town near Madrid two thousand persons died after it in September. In 1580, Sennertus ascribes the death of two thousand persons in Rome to venesection, and states that, where it was omitted, the mortality was not greater than one in a thousand. " Experientia enim hoc compro- bavit, omnes fere mortuos esse, quibus vena ape- riebatur." Forestus, in his Scholia on the same epidemic, suggests a good practical hint, that we ought to distinguish very carefully those cases which might require, from those which might not bear this remedy. Huxham, who had no preju- dice against bloodletting, remarks, " Imo, si vel peripneumoniae aliquid subesset, minime largam, sine maxima virium ruina, plus vice simplici vensesectionem tolerabat: nee in hac solum, sed in omnifebre catarrhali epidemica hoc fere per- petuum notavi." (De Aere, &c. ii. 102.) In Edinburgh it was noticed that those who were bled, in 1733 and 1782, " recovered more slow- ly ;" though others at the commencement seemed to be relieved by the lancet. (Med. Essays, vol. vi. p. 29.) In the influenzas of 1733, 1775, and 1803, in France, bloodletting was generally inju- rious. (Diet, des Sc. Med. Grippe, pp. 356, 359, 363.) Dr. Glass reports that at Exeter, in 1775, venesection "weakened the patient without reliev- ing the pain;" and Dr. Ash considered that "it was never necessary to bleed at Birmingham; that in a neighbouring town, three died who were bled, and all recovered who were not bled." (Lettsom's Mem. of Dr. Fothergill, 4to. p. 627.) Dr. Gray gives it as a general inference from the accounts transmitted to a " Society of Physicians" in 1782, "that bloodletting was by no means conducive to the general cure of the disease." (Med. Com. vol. i. p. 80.) Many physicians bear testimony to the same good rule of practice in the influenza of 1803, as Dr. Bardsley of Manchester, Dr. Kinglake of Taunton, Dr. Rutter of Liverpool, and others. (Med. and Phys. Journ. vol. ix. and x.) Notwithstanding the foregoing authorities, it is admitted by some eminent physicians, that cases now and then occurred in which this remedy was useful. Sir George Baker made this obsep- vation in 1762, in London (p. 29); and in the same city it is somewhat remarkable that in the epidemic of 1775 it was less hurtful than in other places, which was perhaps owing to the more fre- quent complication of the disease that year with pleurisy and peripneumony, at all times no unu- sual circumstance. Opiates at the commencement of the disease almost invariably increased the febrile heat, aggra- vated the headach, in some cases even to delirium, tightened the chest, and stopped the expectoration: but in the decline they proved salutary. A cool temperature, both in drinks, in the air of rooms, and in the quantity of bed-clothes, was found to be useful; while, on the contrary, warm rooms, hot drinks, and cordial sudorifics, aggravated the violence of the disorder. Blisters to the chest, sides, or back, often greatly relieved the stitches and cough ; and ipecacuanha was much extolled, especially in France, for its efficacy, when given in small doses, in assisting expectoration, reliev- ing the oppressed lungs, and correcting the ten- dency to irritation of the mucous membrane of the bowels. A medicine often used with good effect to ease the cough when attended with viscid phlegm, was the solution of gum ammoniac com- bined with oxymel of squills. When recovery was tedious and the strength much impaired, even long before the cough was removed, some bitter infusion, such as that of calumba, cascarilla, or Peruvian bark, with wine-whey and some nu- tritious diet was of great service. The reason why purgatives have been so generally reprobated by practitioners in the influenza, appears to have depended on the fact, that a morbid state of the mucous tissue of the internal surfaces exposed to the air, was often closely connected with a mor- bid tendency in that of the alimentary canal; and, therefore, drastic purgatives, though they might relieve one system or set of organs, yet too often only transferred the disease, as it were, to another, and produced a dangerous debility. [Lobelia inflata was recommended by Dr. Cart- wright of Natchez, (Medico-Chirurg. Rev. for April, 1837, p. 586,) for the not very cogent reason, that " in those diseases affecting the mu- cous lining of the bronchial tubes, the lobelia in- flata comes as near being a specific [1] as tartar- emetic and the lancet in pneumonia and pleu- risy." Lobelia, as elsewhere said, (Practice of Me- dicine, 2d. edit. i. 263, Philad. 1844,) is certainly a valuable sedative, but not deserving of the ele- vated rank that has been assigned to it. The diseases of the bronchial tubes differ, and no one remedy can be applicable to every pathological con- dition. When there was more than usual inflam- mation of the bronchia, in the epidemic of 1837, large doses of the ethereal tincture of lobelia, re- peated at short intervals, with counter-irritation, seemed, according to Dr. Blakiston, to be useful.] IV. Among the phenomena relating to the weather, which seem to have had a connection with epidemic catarrh, either as precursor or at- tendant signs, we may notice extraordinary vicis- situdes, easterly winds, thick or offensive fogs, and diseases, often of a similar kind, among horses, dogs, and cattle. Epidemic catarrh is a disease either of spring or autumn. The spring influen- zas have sometimes occurred when the first heat suddenly followed the winter's cold; and the au- tumnal, when the cold moisture and raw fogs of November have succeeded to the heat of a dry harvest; yet there has not been a uniform con- nection between any one sensible quality of the atmosphere as to heat or cold, rain or drought, wind or calm, and the prevalence of this epidemic; for in different places it has maintained itself un- der the dominion of each of these states of the weather, " et tempori frigidiori et calidiori, et flante tam austro quam Borea, et pluvioso et sere- no coelo, peragravit hasce omnes Europaeregiones, et omnia leca indiscriminatim." (Salius Diversus, cited by Dunning, Med. and Phys. Journ. x. p. 22 INFLUENZA. 143.) In fact, extraordinary vicissitudes have been more remarkable than any thing else: in some places, one peculiar sign of atmospheric intem- perature has been observed, and in other places a different sign ; and the epidemic has frequently fallen capriciously or partially, like the blight over a country, or even over a garden. Short says that "thick, ill-smelling fogs pre- ceded, some days, the epidemic catarrh of 1567. July, August, and September had been very hot and dry; and in the end of September came a very strong cold north wind." (History, &c. vol. i. p. 223.) Riverius, quoted by Saillant in his History of Catarrhal Epidemics, says that just before that of 1580 appeared in France, (at Nismes or Montpe- Iier?) " a prodigious quantity of insects appeared in April and May ; and the roads were covered with them in such a manner, that a person in walking might have destroyed them by thousands." (Diet, des Sc. Med. torn. xix. p. 359.) And Pe- trus Salius Diversus, cited by Dunning, tells us of the birds and brute animals suffering generally the same year. (Med. and Phys. Journ. x. 143.) To these facts we may add the observation of Short, that " after a long continuance of hot, moist weather, attended with southerly winds, at the rising of the dog-star came a cold, dry, north wind ; and from the middle of August to the end of September raged the malignant epidemic ca- tarrh." (Hist, &c. i. p. 260.) Great extremes of the weather preceded the epidemic catarrh of spring 1658, decribed by Willis, (Ihid.) ; and Sy- denham attests that " the epidemic catarrh of au- tumn 1675 immediately succeeded cold and moist weather, which suddenly followed an unusually warm summer." (Syd. Opera, sect. v. ch. 5.) We have no very particular account of the state of the weather in England attending the epidemic catarrh of autumn 1729; but Hoffmann does not hesitate to ascribe its origin in Germany to the uncommon " irregularity and frequent changes of the weather from heat to cold and from cold to heat, &c. which distinguished that and the pre- ceding year, such as he had never before witness- ed ; causing throughout all Germany, Belgium, England, and elsewhere, unusual sickness : « tarn uberi proventu enati fuerint morbi, quam vix alio tempore visum unquam." (Hoffmann, Op. torn. ii. pp. 83, 109.) Within the last century the number of obser- vations on the phenomena in question increases very considerably; and we are thus enabled to make some approximation to general principles. Saillaint's excellent work, (Tableau des Epidem- ics Catarrhales, depuis 1510, jusque celle de 1780), on the continent, and the facts which have been collected in this country, on the catarrhal epidem- ics of 1775, 1782, and 1803, afford us much as- sistance in this inquiry. De Jussieu says that » the influenza of spring 1733 appeared in France immediately after offen- sive fogs, more dense than the darkness of Egypt," (plus epais que les tenebres de l'Egypte. (Diet. Art. Grippe.) Huxham remarks generally that the cause of epidemic catarrh seems to de- pend on a thick, moist, and cold air ; and that in the autumnal months preceding the spring catarrh of 1733, epidemic diseases were very common and fatal among horses. (De Aere, Sec. torn. I pp 73 75.) We find, also, that about Edinburgh coughs and running from the nose in horses were universal in October and November, just before the disease attacked men. (Med. Essays, u. p. 31.) The influenza of spring 1743 was the precursor of the great plague in some parts of Sicily. In England it was not so severe and fatal as in some other parts. About Plymouth, according to Hux- ham, many horses were diseased, and deer per- ished in January. (Webster's Hist. i. 386; and Huxham, op. cit. ii. p. 95, &c.) Sir G. Baker says that the weather in spring 1762, before the epidemic catarrh of that year broke out in London, was extremely irregular; wind, frost, snow, and rain following each other in rapid succession, and with unusual severity. In April and May, intense heat followed ; and beside this, the air underwent very sudden changes from heat to cold and from cold to heat. (De Catarrh. Epid. p. 7.) A hot dry spring and summer preceded the epi- demic catarrh of autumn 1775. Petit says that in France the disease was ushered in by thick noisome fogs (" brouillards fetides"), and a cold rainy autumn. (Art. Grippe, Diet. p. 359.) Dr. Anthony Fothergill says that disease among dogs and horses was general over England before the influenza broke out, (Mem. of Med. Soc. vol. iii, 36) ; and we are also assured that it was preceded by foggy air as well as by disease among dogs and horses in Dorsetshire, and at Exeter; and by un- usual haze, easterly winds, and almost universal cough among the horses in North Wales. (See the Reports of Drs. Pulteney, Glass, and Hay- garth, in Lettsom's Life of Fothergill.) About the 7th of October, 1775, it appeared in the shire of Galloway in Scotland ; " and a continual dark fog and particular smoky smell in the atmosphere prevailed for five weeks, the sun was seldom seen, and though October and November are particu- larly rainy months in that country, little or no rain fell, the wind E S E. and S." (Mem. of Med. Soc. vol. vi. p. 323.) With regard to the influenza of spring 1782, " the spring of this year was remarkably late, with a long prevalence of cold easterly winds; the hedges were not full blown in Cornwall before the beginning of June. A similar state of weather has commonly ushered in this universal malady." (Trotter's Med. Naut. vol. i. p. 362.) Dr. Ham- ilton tells us that » from the first of January till the end of May, throughout most places in the kingdom, the weather was uncommonly unfavour- able ;" and it appears that the latter month " was remarkable in all the meteorological annals of Europe for its unusual degree of cold and hu- midity, with a gloomy and uncommonly dis- turbed state of the atmosphere." (Mem. of Med. Soc. vol. ii. p. 433 and 445.) Dr. Darwin adds h.s testimony, that in this year (1782) « the sun was for many weeks obscured by a dry fog, and appeared red as through a common mist:" and he supposes "the material which thus rendered the air muddy, probably caused the epidemic catarrh which prevailed in that year." (Zoonom. c. ii. 1, } i i I u Says that horses were affected with a cold at the same time, near Exeter. (Med Com merit, vol. ix. p. 414.) Maertens records a strik- INFLUENZA. 23 ing fact relative to the first appearance of this epi- demic at Petersburg, and its connection with a particular change of the weather: " On a cold night the thermometer rose 30° of Fahrenheit; the next morning forty thousand people were taken ill with the influenza." (Med. and Phys. Journ. vol. x. p. 524.) The influenza of spring 1803, as we have said, afforded an occasion for the collection of many valuable observations. It appeared in France some weeks before it invaded this country, and was supposed to be owing to a cold and humid autumn succeeding a dry and hot summer. At Paris it was immediately followed by a severe epidemic ophthalmia, about the time the influenza first appeared in Britain. (Diet, ubi supra.) With respect to unusual extremes in the weather, such are stated to have occurred in Hampshire, Lon- don, Somersetshire, and St. Andrews in Scotland, (Med. and Phys. Journ. x. 313, and Mem. of Med. Soc. vol. vi.) «I am of opinion," says Cu- ming, (Romsey, Hants,) «that the remote causes of this disease originated in the sudden change of atmosphere, a change, I believe, generally felt throughout the United Kingdoms, as well as upon the continent." Epizootic diseases preceded it, in some places among one or two species of animals only, in others among several, as cats, dogs, horses, cows, sheep, swine, in Shropshire, Wor- cestershire, Staffordshire, Cumberland, Hampshire, Lancashire, &c. (Ibid. pp. 288, 379, 316, 414, 426, 444, 482, 576.) At Plymouth » many attri- buted the disorders among the horses to their having eaten insects, which for many weeks were innumerable, and covered the fields in a most ex- traordinary manner whorever there was any length of grass; and this, from the mildness of the season, was general in almost every field." (Med. and Phys. Journ. x. 137.) Disease was very prevalent among sheep in some parts of the north of England, last spring (1831), just before the influenza appeared; and an epidemic catarrh seems to have raged among horses in the south later in the year. The influ- enza of this year was remarkable for this, that it prevailed in some parts of Great Britain in spring, and in other parts in autumn. Its character was generally mild in all. With regard to the weather, an intelligent captain of a regular trader in the English channel declared to the writer of this ar- ticle, that for thirty years past he had no recollec- tion of such a long continuance of a thick and 'foggy atmosphere, as he has had occasion to ob- serve within the last eighteen months, between this country and the south of Ireland. He went so far as to state that he had scarcely made one clear passage from Liverpool and back again during this whole period. One general inference offers itself to our notice on reviewing the foregoing facts, viz. that no par- ticular phenomenon in nature universally charac- terizes the epidemic constitution which precedes, or that which accompanies the disease called in- fluenza; and we are led to conclude that the causes of this epidemic, supposing them to take their rise in atmospherical changes of a universal nature, are far from being marked by uniformity in the signs. At the same time we are bound to admit that the changes from warm weather to cold, J and from cold weather to warm, with dampness, fogs, and easterly winds, have rarely been absent from the catalogue of natural indications. Disease among domestic animals is also to be noted as a very common precursor in many places, and in several distinct visitations of the influenza. [Dr. Graves (op. cit.) suggests that the disease may depend chiefly on telluric influence, or upon some agency connected with variations in the physical conditions, which operate on the external surface of the earth. The suggestion only indi- cates the little knowledge we have of the subject. In regard to the nature of the disease, various opinions have been entertained. Essentially it consists of the collection of symptoms to which the names of catarrh and bronchitis are applied; but along with these, especially in the influenza of 1837, the nervous system has been implicated. By one of the writers on the epidemic, Dr. Blak- iston, it has been designated " an affection of the nervous system, with its concomitant derange- ment in the organs of digestion, and circulation commonly known under the name of nervous fever, accompanied throughout its whole course by irritation of the pulmonary mucous mem- brane," and this view seems to have been embraced by most writers on the subject. Andral, however, (Cours de Pathologie Interne,) concludes that it is a general affection, the nature and cause of which are as unknown as those of the greater part of epidemics, which appear at irregular epochs.] V. The influenza, like every other epidemic disease, has given occasion to medical observers to entertain very opposite views on the question of its contagious property. Were we to draw a general inference from the recorded statements of the majority, we should say that it was not con- tagious ; for the numbers who have given an opinion on this side far exceed the advocates of contagion. But we must not appeal to the ma- jority in order to decide a principle in science. It must, however, be acknowledged, that while indi- vidual or partial occurrences might lead to the supposition that influenza was propagated in many instances by contagious transmission, a compre- hensive survey of facts goes far to establish the contrary opinion ; for some things can hardly be explained on the principle of contagion without having recourse to suppositions that could not be warranted by a sound induction. Upon the whole it would appear that some general cause, if not originating, at least subsisting in the atmosphere, and depending on its changes, progressive also in its movements from place to place and from coun- try to country, gives rise to the disease; but that it is probable that a limited propagation also takes place by personal intercourse, under the influence, and during the prevalence, of the epidemic con- stitution. We have writers affirming that persons who have been visiting or on business in an infected town, have been the first to introduce the epidemic into their own town or neighbourhood; and it cannot be doubted that the members of a family and the inhabitants of a district have often been attacked by the influenza in succession. Hence these things would seem to indicate that the dis- ease was propagated by contagious transmission 24 INFLUENZA more than by some universal medium. But the difficulty of proving the first to be actually the case, must, in the nature of things, be very con- siderable ; for it would appear,—and the remark applies to almost every epidemic disease,—that in many places a tendency to the epidemic has been recognised by clear indications some time before the peculiar combination of symptoms which cha- racterize it have shown themselves, making the moment of actual invasion very doubtful; just as, it is well known, the epidemic imprints its own character for some time after upon the diseases that follow it. And though no epidemic disease with which we are acquainted is so sudden and simultaneous in its attacks as influenza, and there- fore none more emphatically deserves the name of epidemic, nor more decidedly proves a universal cause; yet it is a striking fact that, with all its frequent rapidity of movement over the globe, it has in almost every country been more or less obedient to the laws which govern other epidemics, according to some progressive and consecutive operations that are as much hidden as the efficient cause of attraction. It does, in fact, mostly ob- serve some progressive law in moving over a country and in attacking a given multitude of people, which demonstrates that, however uni- versal may be the cause of an epidemic disease in its purest form, yet if we regard experience, the effects rarely if ever should be expected to appear without some degree of consecutive order. The difference of constitution, of age, of habits, of lo- cality, and of other things, may be quite sufficient to account for the phenomenon of successive attack; and indeed it is what we might expect d priori. If to this we add the probability, and, indeed, necessary inference from the facts, that the cause itself is developed gradually, we shall have less difficulty in accounting for a continuous mode of attack on another principle than that of conta- gion. Though a successive mode of propagation over a country or city is most usual, yet on some occa- sions the spread of influenza over a whole king- dom, within the space of a few days, has been so general as to make the propagation by means of personal intercourse quite incredible, and almost impossible. Besides this, its sudden appearance in ships at sea, which have had no intercourse with land or with other vessels for a considerable time, can hardly be explained on any other sup- position than that of its atmospherical origin. Dr. Anthony Fothergill assures us that « both the epidemics of 1758 and 1775 seized whole families on the same day, often remote from one another, and without any intercourse. (Memoirs of Med. Soc. vol. iii. p. 36.) Again, «the influenzas of 1775 and 1782 seized some persons at sea, while others were attacked on shore, and that without any perceptible communication." (Ibid. 38.) "The appearance of the Influepza in 1803, in England," according to Dr. Woodforde, ««was very sudden, and its attack extremely general, so that it is difficult to say in what or in how many parts of the kingdom it prevailed at first. It is probable that the disease broke out in all at or nearly the same time." (Med. and Phys. Journ. vol. ix. p. 505.) The following fact is very conclusive as to the operation of some general cause; for it is scarcely probable that contagion could be lurking a long Le before, and then should burst forth at the same time in distant points in so remarkab e a manner. Two separate fleets eft the coast of England for different points of destination in the year 1782 , one, under Admiral kernpenfeldt, on the 2d of May, to cruise between Brest and the Lizard; the other, under Lord Howe, on the 6th of the same month, for the Dutch coast: neither fleet had communication with any shore ; and the crews of each were perfectly healthy on sailing from Spithead. But on the 29th of the month, near four weeks after, the crew of the Gohah, one of the ships under Kernpenfeldt, was attacked with influenza, and about the same time the epidemic appeared also in the Rippon, under Lord Howe. The other ships of both fleets were attacked in succession. In fact, so many men of both squadrons, on these remote stations, were rendered incapable of duty, that all were obliged to return to Ports- mouth about the second week in June. (Trans- actions of the Col. of Phys. vol. iii., and Trotter's Med. Naut. vol. i. 364.) If we pay attention to the course or direction of the several visitations of the influenza, we may observe that its general progress is not without some order. It either follows a westerly course, or one from the south towards the north. If its course be westward, it does not usually take ex- tensive leaps over kingdoms, and then return to those it may have missed, as would be likely to happen if nothing more than personal intercourse and the various casualties of travellers' routes ex- erted an influence in determining its course. But it sweeps along the north from the east through Russia, Poland and the north of Germany to Eng- land ; and then wheels round through France and Spain to Italy. And here we cannot but trace a striking resemblance to the career of the epidemic cholera. But if influenza arises in the south, it takes a course from Italy through Spain, France, Britain and the Netherlands, along the shores of the Baltic. In the one case France is attacked before England, in the other after it. Were we to admit that the propagation of an epidemic disease over a space of some hundred square miles in the course of a few days or weeks might be accounted for on the doctrine of conta- gious transmission by means of travellers and the facilities of human intercourse, analogy might sup- ply us with an argument against the admission; for in the case of some of the domestic animals, which do not travel from country to country like man, but are comparatively stationary, epidemic diseases are observed to spread among them; sometimes in as extensive and simultaneous a manner as amongst human beings. VI. The facts we are now to notice seem to afford strong indications of the influence which the general cause that produces epidemic catarrh exerts over the human body with regard to other diseases; and so far they are opposed to the theory that contagion is the cause of it. Webster has remarked that catarrh or influenza is the di< which is most clearly connected with pestilence the torm of malignant angina, dysentery, vellow fever and plague, which it usually precedes.* (Z Hist, of Epid. vol. ii. p. 39 and 48.) This\T isease ce in ow INFLUENZA. 25 servation is partly confirmed by subsequent expe- rience. These facts also show how the general cause is controlled or modified by local peculiari- ties, as well as by constitutional varieties. Sir George Baker tells us, that " while the in- fluenza of 1762 was prevailing in a very mild and tractable form in the villages near Lincoln, that were high and exposed, quinsies, pleurisies, and peripneumonies produced incredible destruction of life in the low neighbouring districts." (De Ca- tar, Epid. p. 19.) Dr. Carrick of Bristol says that " one of the most open and exposed of the buildings on Clifton Hill is Richmond Terrace, which forms three sides of a parallelogram, fronting respectively the east, south, and west. On the east side, not one family, scarcely an individual, escaped the complaint (in 1803), while on the south side a great majority both of persons and families, in all other respects similarly circumstanced, escaped it entirely."— (Young's Med. Literature, p. 575. See also Mem. of Med. Soc. vol. vi. p. 345.) Dr. Binns states that at the time the scarlatina existed at Ackworth School in 1803, the influenza prevailed in the neighbouring towns ; yet that the latter did not attack a single individual of the family at the school, consisting of between three and four hundred persons." (Ibid. p. 351.) Bur- ton-on-Trent, also, in great measure escaped the influenza the same year; and scarlatina, with hooping-cough and measles, were epidemic there in its place. (Ibid p. 405.) " In London the influenza of 1803 superseded or deferred the usual diseases of the spring, as the measles and scarlatina : this is also recorded by Lorry to have been the case in the epidemic catarrh that prevailed in France in 1775 ; but he adds, that during the summer these complaints appeared with more than usual violence and fatality." (Ibid. p. 520.) " At Aberdeen the influenza of 1775 began near the end of November and continued four or five weeks, but did not visit Fraserburg, luhere there was a putrid fever very fatal at that time." (Lettsom's Mem. of Fothergill, p. 642.) At Ches- ter, according to Dr. Haygarth, " the same epi- demic, in 1775, attacked many who were confin- ed to their houses and even to their beds with other ailments." (Ibid. 637.) Dr. Vaughan says, that at Rochester, when the influenza of 1803 ceased, " an exanthematous fe- ver prevailed, which did not appear to attack any except those whom the influenza spared." (Mem. of Med. Soc. vol. vi. p. 589.) Dr. Gibney reports that « at Navan in Ireland, after the influenza of 1803, a low fever, almost constantly prevailing in that town, disappeared for a considerable time." (Med. and Phys. Journ. vol. x. p. 527.) Dr. Currie 6ays that « at Holywell, a populous town eighteen miles from Chester, and where there is a large cotton manufactory, a typhous fever of uncommon malignity had prevailed for a considera- ble time: the manufacturers and inhabitants of the town had not been free from it for more than two years. On the appearance of the influenza in the spring of 1803, the typhus entirely ceased, and only one case of fever has occurred since (nearly three months). I have not for many years known Vol. Ill___4 c this country so healthy as since the influenza dis- appeared." (Ibid. p. 214.) Dr. Rush remarks that, during the prevalence of the influenza at Philadelphia, he saw no sign of any other epidemic, and that the scarlatina an- ginosa, which prevailed during the summer, dis- appeared after the 1st of October, but appeared again after the influenza left the city. It blended itself with every species of chronic complaint." (Rush's Med. Inquiries, vol. ii.) " The influenza was the precursor of the ma- lignant yellow fever, which, commencing in the beginning of September, 1802, at Port Royal and St. Pierre's, Martinique, among the French seamen and soldiers lately arrived from France, committed the most frightful devastations amongst them." (Mem. of M. S. vol. vi. p. 599.) " During the prevalence of influenza at Vienna, from December 1788 to May following, there were scarcely any instances of real pleurisies or peri- pneumonies, though these often appeared during that season in former years." (Dr. Carenus, Med. Comment, vol. xvi. p. 161.) Dr. Chisholm mentions the exemption from the severe influenza of 1789 in its malignant form, after a remarkable change in the weather, of some estates in the island of Grenada, which had been attacked by it in its milder character before the change took place. (Med. Com. vol. xv.) While the influenza of 1762 was in London, peripneumony and angina were unusually and al- most universally prevalent in the country, (Sir G. Baker, de Cat. Epid. p. 18); and Dr. Car- michael Smyth relates, that " although the epi- demical catarrh of 1782 quickly disappeared in the metropolis, it seemed to leave behind it an epidemical constitution which prevailed during the rest of the summer: and the fevers even in the end of August and beginning of September as- sumed a type resembling in many respects the fe- ver accompanying the influenza." (Med. Com. vol. i. p. 71.) After the disease had continued some weeks, it was observed to change its character in several places. In Dublin Dr. Cleghorn remarked that the fever with which the influenza of 1782 was accompanied, became remittent, and sometimes in- termittent ; in London it was intermittent, at Stamford and the Isle of Man, " low and putrid." (Med. Com. vol. i. p. 25.) We can scarcely look over the histories of influ- enza without perceiving a connection between this disease and morbid affections of the mucous sur- ! face of the stomach and intestines. Thus Huxham has recorded the frequent appearance of cholera and diarrhoea in July, September, and October, after the spring influenza of 1733. (De Aere, &c. vol. i. 86 and 88.) The same author describes the " dysenteria cruenta epidemica," which raged at Plymouth and the adjacent country, both before i and after the influenza of 1743 : and he adds that " he did not know whether the former disease j might not be considered a translation of the latter I to the intestines; but he had observed that epi- demic dysentery was very rarely to be met with in the spring. (Ibid. ii. 99, 103.) Sir George Baker follows up his account of the epidemic catarrh of 1762 in London with a de- scription of the epidemic dysentery which imme- 26 INFLUENZA — IN J.... IT Y. diately succeeded it in that city, (Opus cit.); and both he and Dr. Reynolds remarked that in 1775 diarrhoea sometimes followed the attack of influ- enza. (Mem. of Fothergill, supra cit.) Dr. Hamilton states that in the neighbourhood of Newcastle-upon-Tyne, "the influenza of 1782 was accompanied with colic pains and cramps in the region of the abdomen and stomach, and some had purging." (Mem. of Med. Soc. vol. ii. p. 435.) In France, in the influenza of 1803, " gastric ir- ritation was one of the most frequent complica- tions of the disorder, and appeared in some mea- sure to constitute an essential part of it." (Diet. des Sc. Med. Art. Grippe, p. 362.) Dr. Bertram of Hull remarked that some of the attacks of influenza in 1803 nearly resembled cho- lera-morbus, others cynanche tonsillaris : and he goes so far as to express " a firm conviction of the three diseases being different types of the same disorder, and occasioned by the same cause."— (Mem. of Med. Soc. vol. vi. p. 332.) Diarrhoea seems to have preceded, as an epi- demic, the influenza of 1803, at Plymouth Dock, as in 1743 and 1788; for Dr. May says that early in the year " diarrhoea and cholera were very prevalent; so nearly similar to that preceding the influenza of 1788, that to many of his friends he hazarded a pretty confident opinion of an expected return ; and in this he was not deceived." (Med. and Phys. Journ. x. p. 291.) It must be fresh in the recollection of most that the epidemic cholera which in a milder character appeared in many parts of Great Britain last year (1831), and is now running so fatal a career in its malignant type, was preceded by the influenza; and we know that the same herald of that formida- ble epidemic was seen also at Warsaw, Paris, and other places ; and was lately announced even in the United States of America a short time before the cholera made its appearance in the transatlan- tic cities. These facts are collected to show that there is a closer connection between some epidemic dis- eases, both as to their affinity and their causes, than we commonly imagine; and that it is only by a very enlarged view of their phenomena in different countries that we can hope to improve our knowledge in this obscure branch of science. Thomas Hancock. INSANITY. —Sect. 1.-Remarks on at- tempted definitions of Insanity.—Different varieties of the Disease referred to three principal Forms. Writers on insanity are generally agreed as to the difficulty of inventing a satisfactory definition of that disease. It is perhaps impossible to com- prise in a few words a characteristic description of mental derangement which may prove to be of practical use; and it is not an easy matter to discover one that even includes all the essential features of the object which it is proposed to define. The latter of these requisites will be obtained if we describe insanity as consisting in "a disordered state of the functions of the brain, which gives rise to disturbances in the operations of the mind." This definition may correctly be applied to madness, but it also includes a variety of other diseases; and hence it becomes neces- sary to render the description more particular by- exclusions and restrictions. It must be added for example, that the disturbance in the mental operations ensuing from the morbid cause m the brain is not allied to coma or to loss of conscious- ness and sensibility, in order to exclude from the definition apoplexy and disorders of the same class. For a similar reason it has been common to observe that madness is a species of delirium distinct from that which is symptomatic of typhus and other febrile diseases. There are some other morbid states of the brain and of the faculties dependent for their exercise on the functions of that organ, which must in like manner be ex- cluded by express limitations. Such are congen- ital idiotism, and the imbecility of old age. Now | it is obvious that a definition loses all its utility j when it is found necessary to encumber it with so ' many particular restrictions, and it is therefore better to give up the attempt to define insanity in general terms. But the practical purpose of a definition, which is to give a clear and distinct conception of the thing to be described, will be secured if we can determine and classify the various disturbances which the mental operations undergo. These disturbances, however, present very different phe- nomena in different instances of the disease, and we cannot attempt to draw up a concise account of them until we have briefly noted their principal varieties. It is generally supposed that the intellect or the reasoning faculty is principally disordered in per- sons labouring under mental derangement. Mr. Locke made a remark, that "madmen do not appear to have lost the faculty of reasoning; but having joined together some ideas very wrongly, they mistake them for truths, and they err as men do that argue right from wrong principles." From Mr. Lock's time it has been customary to observe that insane persons reason correctly from erroneous premises ; and some instances of hallu- cination, or some particular erroneous impression, have been looked for as the characteristic of the disease, or an essential circumstance in it. Dr. Cullen seems to have had Mr. Locke's observation in his mind when he laid down the definition of madness which occurs in his First Lines. He describes this disease to be «in a person awake a false or mistaken judgment of those relations of things which, as occurring most frequently in life, are those about which the generality of men form the same judgment; and particularly when the judgment is very different from whai the person himself had before usually formed." Cullen at- tempted to draw even this description within nar- rower limits, by observing that « there is generally some false perception of external objects, and that- such false perception necessarily occasions a del.rmm or erroneous judgment, which is to be considered as the disease." That this is by far too limited an account of madness, and only com- prises one, and that by no means the most fre- quent form of mental derangement, eve^erson must be aware who has had opportuuitie* of ex" tensive observation. Of those lunatics whose intellectual faml^i are manifestly disordered, there is always a i"! INSANITY. -ft siderable proportion in whose minds it is impossi- ble to trace any particular hallucination or erro- neous perception or recollection. The rapid suc- cession of thoughts, the hurried and confused manner in which ideas crowd themselves into the mind in a state of incoherence, or without order and connection, is in very many instances among the most striking phenomena of madness. There are, likewise, cases of a different description, in which the intellectual faculties appear to have sustained but little injury, while the feelings and affections, the moral and active principles of the mind, are strangely perverted and depraved; the power of self-government is lost or greatly im- paired ; and the individual is found to be inca- pable, not of talking and reasoning upon any subject proposed to him, for this he will often do with great shrewdness and volubility, but of con- ducting himself with decency and propriety in the business of life. His wishes and inclinations, his attachments, his likings and dislikings, have all undergone a morbid change, and this change appears to be the originating cause, or to lie at the foundation of any disturbance which the un- derstanding itself may have sustained, and even in some instances to form throughout the chief cha- racter or constituent feature of the disease. The older nosologists, Sauvages, Sagar, and Linnaeus, were not wholly unaware of these distinctions; for in their distributions of mental diseases, we find (besides an order of Vesanix or Hallucina- tions, in which erroneous impressions were sup- posed to affect the understanding) another depart- ment styled " Morositates" or "Morbi Pathetici," consisting of depraved appetites and other morbid changes in the feelings and propensities. The disorders, however, which are classed under these heads, are not, all of them at least, strictly forms of insanity ; and Pinel appears to have been the first writer who, with a clear conception of the subject, distinguished a class of maniacal affections under the term of " madness without delirium or hallucination." Pinel, who was an acute and original observer, and whose opinions carry much weight on account of his extensive opportunities of investigating the history of madness, has made the following remark in reference to the sentiments of Mr. Locke. " We may justly ad- mire," he says, " the writings of this philosopher, without admitting his authority upon subjects not necessarily connected with his inquiries. On re- suming at the Bicetre my researches into this disorder, I thought, with the above author, that it was inseparable from delirium," (meaning what is termed by English writers hallucination ;) " and I was not a little surprised to find many maniacs who at no period gave evidence of any lesion of the understanding, but who were under the dominion of instinctive and abstract fury, as if the active faculties alone had sustained injury. The examples given by Pinel in illustration of the above remark were not fortunately chosen, and they are all of one kind, namely, of that in which the principal phenomena of the disease were vio- lent fits of anger or rage. The general observa- tion which the author has so clearly enounced, that insanity consists, in certain cases, in a morbid perversion of the affections and moral feelings ex- clusively, and without any perceptible lesion of the intellectual faculties,'is a fact of the highest importance pathologically and practically, and the opinion of Pinel in this particular deserves the most attentive consideration. It will be found that later practical writers, though they have not made the same statement in so decided a manner, have yet given a testimony which leads to the same result. The following remarks by M. Es- quirol, who is less systematic than Pinel, prove that he was led to a similar conclusion by the strict observation of facts. « The insane conceive an aversion for those per- sons who are most dear to them, revile them, ill- treat them, anxiously shun them, in consequence of their mistrust, their suspicions, and their fears. Prejudiced against every thing, they are afraid of every thing. A few appear to form an exception to this general rule, in preserving a sort of affec- tion for their relatives and friends ; but this feeling of attachment, which is sometimes excessive, sub- sists without confidence in those persons who be- fore the attack of the disease had been the direc- tors of the thoughts and actions of the patient. A melancholic, who is devotedly attached to his wife, is deaf to her counsels and advice. A son would sacrifice his life for his father, but will not make the slightest attempt, in compliance with the entreaties of the latter, to overcome the morbid impression which occasions him so much grief." " This moral alienation is so constant," says M. Esquirol, « that it appears to me to be the pro- per characteristic of mental derangement. There are madmen in whom it is difficult to discover any trace of hallucination, but there are none in whom the passions and moral affections are not disor- dered, perverted, or destroyed. I have in this par- ticular met with no exceptions." " A return to the proper and natural state of the moral affections," says the same writer, " the desire of seeing once more children or friends ; the tears of sensibility; the wish manifested by the individual to open his heart and return into the bosom of his family, to resume his former habits, afford a certain indication of cure, while the contrary dispositions had been a mark of ap- proaching insanity, or the symptom of a threat- ened relapse. This is not the case when there is merely a disappearance of the hallucination, which then only is a certain sign of convalescence, when the patients return to their natural and original affections." (Esquirol, Diet, des Sc. Med., torn. xvi.) If the opinion expressed by these writers is founded on real facts,—and that it is so the writer of the present article is well assured from ample proofs afforded by his own observation,—it must be evident that it leads' to very important results. It will be necessary, in conformity with it, and with the varieties of phenomena which the dis- ease really presents, to classify the different forms of madness or insanity under the following divi- sions. 1. Moral insanity, or madness consisting in a morbid perversion of the natural feelings, affections, inclinations, temper, habits, and moral dispositions, without any notable lesion of the intellect or knowing and reasoning faculties, and particularly without any maniacal hallucination. 28 INSANITY. 2. Intellectual insanity, or madness attended with hallucination ; in which the insane person is impressed with the belief of some unreal event as of a thing which has actually taken place, or in which he has taken up some notion repugnant to his own experience and to common sense, as if it were true and indisputable, and acts under the influence of this erroneous conviction. 3. There is another well-marked division of maniacal cases, in which the whole mind, if we may use the expression, seems to be equally de- ranged. The most striking phenomena in this form of the disease are the rapidity and disorder with which the ideas follow each other, almost without any discoverable connection or associa- tion, in a state of complete incoherence and con- fusion. It is impossible to fix the attention of the patient long enough to obtain a reply to the most simple question. His understanding is wholly lost in the constant hurry of ideas which crowd themselves upon him, and which appear to exceed the power of distinct utterance, while his habits betray a corresponding degree of restless activity and extravagance. The most appropriate designation in our lan- guage for this species of disease is incoherent mad- ness, a term given to it long ago by Dr. Arnold. It is named by Pinel dementia or demence, de- mentedness. Pinel has given an admirable defini- tion of it: " Rapid succession, or uninterrupted alternation of insulated ideas, and evanescent and unconnected emotions; continually repeated acts of extravagance ; complete forgetfulness of every previous state; diminished sensibility to external impressions; abolition of the faculty of judg- ment ; perpetual activity." If we are correct in assuming that all the va- rieties of mental derangement may find their place under one of the three descriptions we have thus marked out, a definition or short nosography of madness will be furnished by enumerating the characteristics of the three forms. We may then describe insanity as « a chronic disease manifested by deviations from the healthy and natural state of the mind ; such deviations consisting either in a morbid perversion of the feelings, affections, and habits, or in disturbances of the intellectual facul- ties, under the influence of which the under- standing becomes susceptible of hallucinations or erroneous impressions of a particular kind; or, thirdly, in a state of mental incoherence, or con- stant hurry and confusion of thoughts." We shall now endeavour to trace an accurate description of the actual phenomena of insanity, containing the results of long and attentive obser- vation. In discriminating the different varieties of the disease, we shall neither deviate further than is necessary from the arrangements of former writers, nor shall we follow in every respect the nosological divisions which they have adopted. The reader will, if we are not mistaken, find data in the following outline sufficient to confirm and illustrate the preceding remarks, and to show how far the distinctions we have endeavoured to estab- lish are complete. Sect. II. — Phenomena of Madness de- scribed. 1. First Appearances of the Disease.—The first appearances of madness are very *«j?g£jj the various forms of the disease and in dirteren Zes Sometimes the complaint breaks out at once, without any previous inaicaUon^; the man, ners of the patient are observed to be unusually impetuous; his conversation hurned; his mind full of projects, which he pursues with restless activity. He betrays the absolute derangement of his understanding by announcing some false and absurd impression, or by acting upon it When his attempt is resisted, or when by acci- dent he explains the motive which incited him, his condition is at once made evident, and the necessity of restraint becomes obvious. Such is the mode in which insanity makes its attack in the greater number of cases. In other instances the actual appearance of disturbance in the intel- lect is preceded by a period of uncertain duration, in which an unsound state of mind exists, but displays itself in a different manner. A certain waywardness or singularity of character, an un- steadiness in pursuits and inclinations, a fickleness or capriciousness of temper and habit, is observed for some time before the individual is set down by his relatives as a lunatic. This stage of the dis- ease may last for years. M. Pinel mentions the case of a man who believed his wife to have been deranged only six months, at the commencement of which period she had sustained an attack of violent mania, but after repeated inquiries was at length convinced that she had not been in a sound state of mind for fifteen years. The same writer likewise observes that in many instances the origin of mental derangement has been referred, on tracing its history, to a period of four, ten, or even of fifteen or twenty years before the time when it became fully manifest, or when a disor- dered state, previously ambiguous, changed its character into that of ordinary or decided mania. Cases of disease affecting the mind, such as we have described, and in which the succession of symptoms and the development of the com- plaint follow the order just pointed out,—a certain period either of melancholy dejection or of morbid excitement, attended with a disturbed and unna- tural state of the feelings, temper, and habits, pre- ceding, and after a time ushering in a clearly marked attack of insanity—are in fact only exam- ples of a transition from one form or state of men- tal disorder to another, which is more strongly characterized and more easily distinguished. There are, however, numerous instances in which phenomena similar to those of the previous stage last for many years, perhaps during life, some- times maintaining their ambiguous and undefined character, at others becoming aggravated in degree, but without undergoing a transition into the pe- culiar form of madness attended with marked dis- turbance of the intellectual faculties. Of this description are the cases of mental disease which we purpose to distinguish under the term of moral insanity. First Form of the Disease.-Moral Insanity. to TonilH men1tal disease has **" saiJ ab°'e to consist of a morbid perversion of the feelings, ^rTus habltS'.without «»y hallucination ^ tandT T U°n imFeSSed Upon the up- standing, it sometimes coexists with an anna- rently unimpaired state of the intellectual facuE. INSANITY. 29 There are many individuals living at large, and not entirely separated from society, who are affect- ed in a certain degree by this modification of in- sanity. They are reputed persons of singular, wayward, and eccentric character. An attentive observer may often recognise something remarka- ble in their manner of existence, which leads him to entertain doubts as to their entire sanity, and circumstances are sometimes discovered on inquiry which assist in determining his opinion. In many instances it is found that there is an hereditary tendency to madness in the family, or that several relatives of the person affected have laboured under other diseases of the brain. The individual himself is discovered in a former period of life to have sustained an attack of madness of a decided character. His temper and dispositions are found on inquiry to have undergone a change; to be not what they were previously to a certain time; he has become an altered man, and this difference has perhaps been noted from the period when he sustained some reverse of fortune, which deeply affected him, or since the loss of some beloved relative. In other instances the alteration in his character has ensued immediately on some severe shock which his bodily constitution has undergone. This has been either a disorder affecting the head, a slight attack of paralysis, a fit of epilepsy, or some fever or inflammatory disorder which has produced a perceptible change in the habitual state of the constitution. In some cases the alter- ation in temper and habits has been gradual and imperceptible, and it seems only to have consisted in an exaltation or increase of peculiarities which were always more or less natural or habitual. In a state such as that above described, many persons have continued for years to be the sources of apprehension and solicitude to their friends and relatives. The latter in many instances cannot bring themselves to admit the real nature of the case. The individual follows the bent of his in- clinations ; he is continually engaging in new pursuits, and again relinquishing them without any other motive than mere caprice and fickle- ness. At length the total perversion of his affec- tions, the dislike and even enmity manifested to- wards his dearest friends excite greater alarm. When it happens that the head of a family labours under this ambiguous modification of in- sanity, it is sometimes thought necessary from prudential motives, and to prevent absolute ruin from thoughtless and absurd extravagance, or from the result of wild projects and speculations, in the pursuit of which the individual has always a plausible reason to offer for his conduct, to make some attempt with the view of taking the manage- ment of his affairs out of his hands. The laws have made inadequate provision for such contin- gencies, and the project is often unsuccessful. If the matter is brought before a jury, and the in- dividual gives pertinent replies to the questions that are put to him, and displays no particular hallucination,—a feature which is ordinarily looked upon as essential to madness,—it is most proba- ble that the suit will be rejected. Several practical writers have left a testimony, which is sufficiently conclusive, as to the exist- ence of moral insanity, though they have not de- signedly and in set terms marked it as a distinct form of the disease. We have already observed that M. Esquirol has stated his opinion to be, that moral alienation, or a perverted state of the affections, is, rather than intellectual aberration, the characteristic of mental derangement. M. Georget likewise describes the state we have alluded to as a particular modifica- tion of madness. He observes " that individuals predisposed to mental disease by a faulty educa- tion or by previous attacks, have often continued for a long time, or perhaps even during their whole lives, to attract observation by caprices in their deportment, by something eccentric in their manner and habits of life, by an ill-regulated fondness for pursuits of the fancy, and the mere productions of the imagination, combined with a striking inaptitude in the study of the exact sciences." The last-mentioned particular will scarcely be allowed to constitute a characteristic trait of madness in this country, whatever may be the case in France. " These persons are noted," continues the same writer, " for singularity of opinions, of conduct, for transitory fits of intelli- gence, or sallies of wit, which are too strongly contrasted with their habitual state of nullity or monotony ; by a levity in thoughts, a weakness in judgment, a want of connection in their attempts at reasoning. Some individuals are presumptuous, desirous of undertaking every thing, and capable of applying themselves to nothing; others are extravagant and mobile in the utmost degree in their opinions and sentiments; many are sus- ceptible, irritable, choleric, and passionate ; some are governed by pride and haughtiness without bound ; a few are subject to vague anxieties or to panic terrors." It must be observed that, although M. Georget has described this state of disease as a first stage, or as the period of what he terms with M. Esqui- rol the incubation of madness, yet, as he says that it often lasts through the life of the indi- vidual, we may consider his testimony as given, in point of fact, in favour of the real existence of moral insanity as a particular modification of disease. Individuals labouring under this disorder are capable of reasoning or supporting an argument on any subject within their sphere of knowledge that may be presented to them, and they often display great ingenuity in giving reasons for their eccentric conduct, and in accounting for and justifying the state of moral feeling under which they appear to exist. In one sense, indeed, their intellectual faculties may be termed unsound, but it is the same sense in which persons under the influence of strong passions may generally be said to have their judgment warped, and the sane or healthy exercise of their understandings im- peded. They think and act under the influence of strongly excited feelings, and a person ac- counted sane is under such circumstances prover- bially liable to error both in judgment and conduct. We have already had occasion to observe that the existence of moral insanity as a distinct form of mental derangement has been recognised by Pinel. The following example recorded by that writer is a characteristic one : 30 " An only son of a weak and indulgent mother was encouraged in the gratification of every ca- price and passion of which an untutored and vio- lent temper was susceptible. The impetuosity of his disposition increased with his years. The money with which he was lavishly supplied re- moved every obstacle to the indulgence of his wild desires. Every instance of opposition or re- sistance roused him to acts of fury. He assaulted his adversary with the* audacity of a savage ; sought to reign by force, and was perpetually em- broiled in disputes and quarrels. If a dog, a horse, or any other animal offended him, he instantly put it to death. If ever he went to a fete or any other public meeting, he was sure to excite such tumults and quarrels as terminated in actual pugilistic rencontres, and he generally left the scene with a bloody nose. This wayward youth, however, when unmoved by passions, pos- sessed a perfectly sound judgment. When he became of age, he succeeded to the possession of an extensive domain. He proved himself fully competent to the management of his estate, as well as to the discharge of his relative duties, and he even distinguished himself by acts of benefi- cence and compassion. Wounds, law-suits, and pecuniary compensations were generally the con- sequences of his unhappy propensity to quarrel. But an act of notoriety put an end to his career of violence. Enraged with a woman who had used offensive language to him, he precipitated her into a well. Prosecution was commenced against him, and on the deposition of a great many witnesses, who gave evidence to his furious de- portment, he was condemned to perpetual confine- ment in the Bicetrice." The morbid and irregular excitement of the ac- tive propensities, and the total want of self-control, which are so conspicuous in moral insanity, dis- play themselves in various ways. Almost every passion or feeling of the mind gives in different cases the character to the disease when displayed under a certain modification, which it would not be easy to describe in accurate terms. Violent gusts of passion breaking out without cause, and leading to the danger or actual commission of serious injury to surrounding persons, are the features of disease in most of the cases mentioned by Pinel. These were examples of madness, consisting in intense irascibility without lesion of the understanding. There are other instances in which malignity has a deeper die. The indivi- dual, as if actually possessed by the demon of evil, is continually indulging enmity and plotting mischief, and even murder, against some unfortu- nate victim of his malice. When this is con- nected with the false belief of some personal in- jury actually sustained, the case does not fall under the head of moral insanity, simply so termed. It involves hallucination or erroneous conviction of the understanding. But when the morbid phenomena include merely the expressions of intense malevolence, excited without ground or provocation, actual or supposed, the case is 6trictly one of moral madness. And such in- stances are more frequent than it will be easy for many persons to believe. Some maniacs display their condition by a propensity to commit every species of mischief, INSANITY. "though devoid of any feeling of malevolence. A case of this description, strongly mark d»« lately pointed out to the writer of this article in iheYo'rk Lunatic Asylum, by Dr. » 'he able and intelligent physician to that institu ion 1 h individual is a youth of good temper, cheerful an active, having no defect of intellect whatever that could be discovered, even after long observation He is continually prone to commit every kind of mischief in his power; and not long ago escaped from his confinement and made his way to Bishop Thorpe Palace, with the design to set it on fire. Dr. Wake has given his assurance that several cases have occurred precisely similar to that above related in all essential symptoms, during his attendance at the asylum, which has continued seventeen years, and that he considers no point in the history of madness better established by facts than the existence of moral insanity, strictly and exclusively so termed, and in conformity with the definition above laid down. A large number of cases falling into this divi- sion of diseases, are those in which a disposition to melancholy and dejection of mind exists, with- out any illusion of the understanding connected with it. A constant feeling of gloom and sadness clouds all the prospects of life: the individual, though surrounded with all the comforts of exist- ence, and even, exclusively of his disease, suffer- ing under no internal source of disquiet, at peace with himself, with his own conscience, with his God, yet becomes sorrowful and desponding. All things, present and future, are to his view involved in dreary and hopeless gloom. This tendency to morbid sorrow and melancholy, as it does not de- stroy the understanding, is often subject to control when it first arises, and probably receives a pecu- liar character from the previous mental state of the individual, from his education, and his reli- gious or irreligious character. Persons of well- regulated minds, when thus affected, express grief and distress at the inaptitude of which they are conscious to go through the active duties of life : frequently they feel a horror of being driven to commit an act of suicide or some other dreadful crime. This idea haunts them, and ren- ders them fearful of being a moment alone. It, however, subsides, and such cases often terminate in recovery. Persons of an opposite character give themselves up to txdium vitie, to morose disgust; they loathe their very existence, and at length, unless prevented, put an end to it. A propensity to theft is often a feature of moral insanity, and sometimes it is the leading if not the sole characteristic of the disease. The writer of this article has lately seen a lunatic, confined in an asylum, who would only eat when he had stolen food, and his keeper made it a constant practice to put into some corner within his reach various articles destined for his sustenance, in order that he might discover and take them fur- tively Many instances are upon record of indi- viduals noted for a propensity to steal, without the desire of subsequent possession, though in other respects of sound mind, or at least not "gene- rally looked upon as deranged. Probably some of these would afford, if accurately scrutinized examples of moral insanity, whilst others mS be found referable to eccentricity of character INSANITY. 31 The discrimination—if indeed the two things are essentially different—could only be made in par- ticular instances by taking into the account a variety of circumstances, such as the hereditary history of the individual and his consanguinity with persons decidedly insane, his former cha- racter and habits, and the inquiry whether he has undergone a change in these respects at some particular period of his life. This form of insanity has been, if we are not mistaken, in many instances the real source of moral phenomena of an anomalous and unusual kind, and of certain perversions of natural incli- nation which excite the greatest disgust and even abhorrence. In some instances moral insanity displays itself in a want of self-government, in a continual ex- citement, and unusual expression of feeling, or in thoughtless*and extravagant conduct. A female, modest and circumspect, becomes violent and ab- rupt in her manners, loquacious, impetuous, talks loudly and abusively against her relations and guardians, before perfect strangers. Sometimes she uses indecent expressions, and betrays without reserve unbecoming feelings and trains of thought. Not unfrequently persons affected with this form of disease become drunkards; they have an un- controllable desire for intoxicating liquors, and a debauch is followed by a period of raving mad- ness, during which it becomes absolutely necessary to keep them in confinement. Individuals are occasionally seen in lunatic asylums who under such circumstances have been placed under con- trol. After the raving fit has passed off, they demand their release; and when they obtain it, at the first opportunity resort to their former excesses, though perfectly aware of the consequences which await them. A form of mental disease has been described by some writers, which, though not of frequent oc- currence, is occasionally seen, and is well known to those who have extensive means of observation. It is peculiar to old age, and has been termed deli- rium senile, and by Dr. Burrows, who has accu- rately distinguished it, senile insanity. It consti- tutes a variety of moral insanity. This disordered state makes its appearance in old men who have never before been insane or suspected of any tendency to mental derangement. It consists, like other forms of moral insanity, in a morbid excitement of passions and a remarkable perversion of the temper and propensities. The whole moral character of the person is changed. " The pious," says Dr. Burrows, " become impi- ous, the content and happy discontented and mis- erable, the prudent and economical imprudent and ridiculously profuse, the liberal penurious, the sober drunken." In some elderly persons, impulses which had long been effete become of a sudden excited, and a strong tendency to vicious habits is displayed. " In fact, the reverence which age and the conduct suited to it always command, is con- verted into shame and pity at the perversion of those moral and social qualities which, perhaps, have hitherto adorned the patient's declining days." This description coincides accurately with the character of moral insanity. There are instances, though rare, of the appearance of hallucinative madness in old persons, but the case we have now ] described is of a different character, and consists in a disordered condition of the moral or active powers alone. The following cases will afford some obser- vations illustrative of the history of moral in- sanity. J. K—, a farmer, several of whose relatives had been the subjects of mental derangement, was a man of sober and domestic habits, and frugal and steady in his conduct, until about his forty-fifth year, when his disposition appeared to have be- come suddenly changed in a manner which excited the surprise of his friends and neighbours, and occasional grief and vexation in his family. He became wild, excitable, thoughtless, full of schemes and absurd projects. He would set out and make long journeys into distant parts of the country to purchase cattle and farming-stock, of which he had no means of disposing ; he bought a number of carriages, hired an expensive house ready fur- nished, which had been inhabited by a person much above his rank, and was unsuitable to his condition ; he was irascible and impetuous, quar- relled with his neighbours, and committed an as- sault upon the clergyman of the parish, for which he was indicted and bound to take his trial. At length his wife became convinced that he was mad, and made application for his confinement in a lunatic asylum, which was consequently effected. The medical practitioners who examined him were convinced of his insanity by comparing his late wild habits and unaccountable conduct with the former tenor of his life, taking into considera- tion the tendency to disease which was known to prevail in his family. The change in his character alone had produced a full conviction of his mad- ness in his friends and relatives. When ques- tioned as to the motives which had induced him to some of his late proceedings, he gave clear and distinct replies, and assigned with great ingenuity some plausible reason for almost every part of his conduct. After a period of time passed in great seclusion, his mind became gradually tranquillized; the morbid excitement of his temper and feelings disappeared; he was set at liberty, and has since conducted himself with propriety. A brother of the above patient has been at two different times confined in the same asylum, la- bouring under symptoms of derangement in all es- sential particulars resembling those above detailed. His disorder has consisted chiefly in morbid ex- citement, wildness and irregularity of conduct, dif- fering from his usual habits and character, with- out any hallucination or disturbance of the in- tellectual faculties. He has on both occasions remained in the asylum until he was fully con- valescent, and after his departure has acknow- ledged his conviction that he had been deranged, and in a state requiring control and seclusion from society. Abraham B-----, a working tradesman, of in- dustrious habits, conducted himself with propriety until about forty-six years of age, and had accu- mulated a considerable property from the fruits of his exertions. About that period he lost his wife, and after her death became more and more penu- rious. At length he denied himself the comforts, ' and in a great measure even the necessaries of [ life, and became half-starved and diseased; his 32 INSANITY. body was emaciated and beset with scaly erup- tions. Mr. S-----, a gentleman who had long known him, hearing of the condition into which he had sunk, sent a medical practitioner to visit him, by whose advice B was removed from a miserable dirty lodging to a lunatic asylum. Mr. S-----, who was present on the occasion, observed that Abraham B-----, previously to his quitting the room in which he had immured himself, kept his eyes fixed on an old trunk in the corner of the apartment. This was afterwards emptied of its contents, and in it were found, in the midst of va- rious articles, dirty bank-notes, which had been thrown into it apparently at different times, to the value of more than a thousand pounds. Abraham B-----, after his removal to an asylum, where he had wholesome food and exercise, soon began to recover from his bodily infirmities, and at length became anxious to be at large. The writer of this article visited him, and conversed with him for some time, in order to ascertain his mental condi- tion. He betrayed no sign of intellectual delusion, nor did it appear that any thing of that description had ever been a part of his complaint. His replies to questions were rational according to the extent of his natural capacity. He was determined to go and manage his property, and get a wife who should take care of him. In a few days after his release he was married to a servant belonging to the lunatic asylum where he had been confined. His new wife found after some months that it was impossible to endure the strange conduct of her husband, and after trying various experiments, brought him back to the asylum, with a certificate from a medical man, who had examined him and declared him to be insane. He still remains in confinement, and his derangement is now more complete than formerly, as it plainly involves his intellect. He now raves against his wife, declares that she is married to her own brother, vows bitter revenge for the injuries he has sustained, and ve- hemently demands his release whenever he is vis- ited by the inspecting magistrates. Abraham B-----'s case was at first merely a perversion of moral habits. If the real nature of this case was otherwise in any degree doubtful, it is rendered obvious by the more decided madness which has since appeared. Very clear indications of a disturbed intellect appeared in his manners and expressions soon after the commencement of his second confinement. It is probable that many instances of extreme avarice and penury, as those of Elwes and Dan- cer, and other celebrated misers, were in reality cases of disease. Whether such individuals were proper objects for confinement is quite another question. In the case of Abraham B----- the interference of others was necessary in order to preserve his existence. The cases above detailed resemble each other in many particulars, and especially in the circum- stance that the morbid perversion of habits which characterized each of them took its rise without any cause that could be distinctly traced. In the following instance the appearance of analogous derangement was preceded and probably caused by constitutional disease, and by the suppression of a long-continued and habitual discharge from the lungs. The case we are about to relate is a tolerably characteristic example of moral insanity. During one period of its course, when aggravated by tern- porary circumstances, it indicated some tendency to assume the form of monomania. The patient displayed a proneness to suspicion, and to enter- tain unfounded impressions connected with the motives and characters of individuals. But these impressions never became deeply fixed or took a permanent hold of the mind, and they soon dis- appeared. For some years both previously and subsequently to the period alluded to, the com- plaint wore that appearance which has, we trust, been correctly designated under the term prefixed to the present section. The account of this case is but slightly abridged from a narrative drawn up by a near relative of the patient. A. M-----is a maiden lady, aged about 48, of short stature, and somewhat deformed; her na- tural disposition was steady and industrious. She accomplished her undertakings by dint of applica- tion rather than by energetic or sudden efforts. She was constant rather than ardent in her attach- ments, free from resentment, never the subject of lively emotions; a great respecter of truth, just and very exact in all that she said or did. Her charitable acts were commensurate with her means, deliberate, and the result of principle rather than arising from the mere impulse of compassionate feeling. She was cautious and reserved in her communications, and scarcely if ever formed any familiar and particular intimacies with young persons of her own sex. Being de- barred by her infirmities from associating with the young and active, she seemed more like an adult member of the family than a child. She was very clever in arithmetic and in all matters of business, and was fond of regulating and controlling the little affairs of those who formed the domestic cir- cle surrounding her. Young persons and servants, finding that they derived advantage from her ad- vice, generally gave her an opportunity of gratify- ing her inclination. Her dress, which was always plain and in good taste, was to her an object of greater attention than it often is to persons of fashion. In March 1822 she was attacked by severe in- flammation in the lungs, attended by expectoration of bloody mucus. This was the first time in het life when it was necessary to confine her to bed. She submitted with great reluctance to the restric- tions that were needful for her recovery, and would not be persuaded until she had heard the opinion of an old friend of her family, who is a medical practitioner, that the means adopted were proper and required by her case. She was then, however, in a great measure reconciled, and after seven or eight weeks was so far recovered as to bear a removal into her native county. At this period nobody believed that she would survive another winter. Her restoration to her usual state of health was very slow, and her sister, who was her constant companion, perceived with sor- row that her temper was now much changed. bhe appeared restless, always wishing to go some- where, or to do something to which she was une- qual ; becoming unjustly irritated when she could not urge her sister, whose health and spirits were INSANITY. 33 declining, to fall in with her ideas, and occasion- ally giving way to reproaches which were keenly felt. She tried every method of persuasion to induce her sister to go to the neighbourhood of London, though for the preservation of her life the latter had been obliged to give up the custom of spending the winter there, and the attempt was considered dangerous to her. Every inducement, every argument was suggested to promote this favourite object: other towns were too warm and too cold, too hilly, too much intersected with water, too foggy. In 1827 she determined to go without her sister to H-------, near London. She went, and from her letters her sister perceived that she was living in a state of excitement far surpassing that of her former habits; paying short visits to friends in the surrounding villages, going out in the common short stages, without so much regard to weather as was usual to her even in the summer; receiving small parties at home, attending a very crowded church, writing a great many letters, &c. &c. She used to write to her sister in rather a boastful style, frequently men- tioning her good health and high spirits, as if to justify her choice of a residence near the metro- polis. When the sisters met during the summer at their house in-----shire, her high spirits were gone, she looked more aged than the time elapsed would have led any one to expect, took less in- terest in her garden, appeared exhausted, and, without contributing her share to the conversa- tion, used frequently to sleep in her chair. She lay much in bed, nursed herself up, and in Octo- ber went again to H-----, as much agog as ever. Another winter passed much as the preceding one had done. She spoke much again of her high spirits, visited much, was observed to be unusually liberal in her presents to most of her acquaintances. A second summer of inertness was succeeded by a winter at H-----. She was now weak, indis- posed for visiting, and, in fact, so much worse as to be unable to follow her inclinations. In the spring of 1830 she had an attack of the same na- ture as that in 1822, but not so severe or lasting. In the summer she was nearly as before, and quite as eager to resume her plans, as enthusiastic in her commendations of every body and every thing atH-----. About this time some riots took place in Lon- don, and more were apprehended. She now ex- pressed herself as apprehensive that " very awful times were at hand," wrote frequent letters to her sister full of indecision, and expressive of distrust in her servants, her host and his family. A friend who called upon her " was shocked to find her in so low a way." He thought her unfit to be alone, and she was unwilling to adopt any plan for leaving her lodgings, or having any one with her. She said she should be happy with her sister, and knew that she should be taken care of by the lat- ter, but dreaded becoming a burden to her and making her ill; yet feared that if she did not go to her sister, " some one would put her where no one would know, and cause her to sign papers which she ought not to sign." She was evidently apprehensive of being sent to a lunatic asylum. She thought her host was a writer of " Swing letters,"* and dreaded that he might fill the house * It may hereafter require to be explained that, about Vol. III. — 5 with combustibles, and blow it up with her in it. A medical man who was taken to see her, said that she was in a state of great mental excitement, and ought to be taken to her sister as soon as pos- sible. The frost was severe when she was escorted to her sister, who was then settled at Bristol, yet she took no cold, experienced no injury from fatigue, and lost that feeling of terror to which she had for some time been subject. Since she has been with her sister, she has been increas- ingly obstinate, suspicious, undecided, restless, parsimonious even to meanness, indisposed to any employment, bodily or mental, except as far as relates to a most troublesome interference with the most minute actions of others. Could she have her own way, she would control the food, dress, and employment of every one near her. She has become negligent in dress, and comparatively dirty in her habits, yet has an insatiable desire for new clothes, which she never finds the right time to wear. She is constantly predicting her utter ruin, is sure she will not have money enough to live until such and such a time; knows that enough will not be found to pay Dr.-----; knows he will not let any one of so shabby an appearance be long in his house ; does not know where she shall go when he is tired of her; thinks that " it is the devil that makes her behave as she does;" " that her heart is hardened to do what she ought not to do;" " she is like the man spoken of in the Gospel, who could not be bound even with fetters." She sees people look at her; hopes they don't think she drinks too much; is quite sure she never did. These impressions are continually varying ; but no sooner is her mind tranquillized on one subject than anothei*source of disquietude arises, so that she exhausts every person who is long with her. Her bodily health is better than j it was for years previous to her mental derange- ment. A constitutional asthma, to which she has J been subject from the age of six or seven years, has nearly subsided, and the habitual profuse ex- pectoration has considerably diminished. She wears less clothing, and appears less sensible to cold or damp than heretofore. | The writer of this article has had several inter- views with the subject of the foregoing relation, during some of which she gave replies to a va- riety of questions referring to the past and actual state of her health, both bodily and mental. No impression could be traced in her mind that bore the character of maniacal hallucination. The circumstance most observable in her condition was a perpetual disposition to find fault with every action, even the most trivial, that was witnessed by her. When asked if she was not aware of this propensity, she seemed to give an unwilling affirmative to the question, and she was plainly aware of the fact, for on the inquiry being made whether the habit had only existed of late years, or had been a pait of her natural character, she steadily averred that such was not her natural dis- position, " that she was formerly very different." The preceding cases present no great difficulty as to the conclusion to be adopted respecting the nature of the disorder ; such, at least, was the the period above mentioned, the threatening letters of incendiaries in various parts of the country frequently bore the signature of Swing. 34 INSA opinion of all the medical practitioners who ex- amined personally the individuals. We now pro- need to mention an instance of moral peculiarity which will not allow of so decided an opinion. Miss A. N----- is a maiden lady of very sin- gular aspect and manners. She has for many years estranged herself from nearly all the friends of her family, formerly a large circle, and asso- ciates almost exclusively with her domestics, and one relative who lives with her. Her chief amuse- ment and delight is to invent and relate the most unfounded, and sometimes the most absurd and ridiculous stories. Sometimes she has displayed mortification when in danger of being detected in the invention of these falsehoods, or when ques- tioned respecting them. Her expression of coun- tenance is sometimes very wild and peculiar. She has never shown any decided mark of mental de- rangement, nor is she considered as insane, thoutrh it has frequently been observed by those who have known her, " that they should not at any time be surprised to hear of her being mad." No person would venture to pronounce this lady to be insane, or at least to found any proceeding upon the opinion ,- and yet it is highly probable that her eccentricity depends upon constitutional peculiarity. One of her parents was decidedly insane during a considerable period of life, and the other, as well as several ancestors and relations by blood, laboured under diseases of the brain, of which fatuity in different decrees was the result. It is generally admitted that there are few ques- tions which physicians are called upon to decide, of more difficult determination than that which relates to the existence or non-existence of insanity in examples which present no obvious and clearly discoverable disturbance in the state of the intel- lectual faculties. It may be apprehended that the perplexities with which this subject has been en- vironed, will rather be increased than diminished by the recognition of a form of mental derange- ment admitting the designation here adopted. But the real facts of a difficult question must be known and described in their true relations, before a solu- tion can be sought with any prospect of advan- tage; and if we are not mistaken in the view of this subject and the facts connected with it, which we have adopted, it will be found that something is gained by admitting a position which places the inquiry relative to the existence of insanity in a different light from that in which it has most fre- quently been regarded. Those who are interested in studying the rela- tions of this disease will do well to consult the able and well-known work of Dr. Conolly. The question how far persons labouring under merely moral insanity are incapacitated for sustaining the relations of society, belongs to medical juris- prudence. 3. Second Form of Insanity. Madness attended with Hallucination.—We now proceed to varieties of disease which are of far more easy discrimina- tion than that species of madness which involves merely a perversion of the moral affections and habits. When the patient is found to labour under a disturbed condition of the understanding, when a morbid delusion or hallucination is im- pressed upon his mind, no doubt can be enter- tained as to the actual existence of insanity. By NITY. khe term hallucination we mean to express.what Cullen and Pinel denote by that of dc"r,um' ™ I a belief of unreal events or relations, apprehended under the influence of disease to be actual and real, or some notion repugnant to common sense, impressed upon the mind as true and indisputable, the patient acting under the influence of his errr> neous conviction. There are two very different states of disease attended with this symptom. In one the under- standing is, when exercised on many subjects, comparatively clear, and the morbid impressions are partial; in the other, the disturbed condition of the intellectual faculties involves all the opera- lions of the mind. These states are respectively termed monomania, and mania or ordinary mania. Each of them requires a separate consideration. Of Monomania. — Cases of partial insanity have been by former writers distinguished by the term melancholia, and it has been supposed that a majority of them are of the description by which that term was suggested, involving gloomy im- pressions and dejection of mind: the designation of mania has been at the same time applied to raving madness, or insanity accompanied by vio- lent excitement. This distinction is laid down in the most explicit terms by Van Swieten. " A ma- nia distinguiter melancholia, quod nondum adsit saevus ille furor, qui in maniacis observatur. Pra> terea et illud signum diagnosticum melancholia? est, quod uni et eidem cogitationi pertinacissime in- haereant tales segri, et fere circa hanc illamve opi- nionem delirant tantum ; in reliquis omnibus sanam ostendunt mentem et saepe acutissimum in- genium." It was well observed by M. Esquirol, that the distinction connected with this appropria- tion of terms is not uniformly supported by facts, as the impressions of partial madness are not always of a gloomy chaiacter : the mind, in this form of disease, is not in every instance abandoned to sorrow and melancholy. The term monomania, meaning madness affecting one train of thought, or involving only a single morbid impression, was on these considerations substituted, and has gene- rally been adopted of late times instead of melan- cholia. The notion, however, which many persons en- tertain as to the nature of the disease thus desig- nated, is very far from being in general correct It is supposed that the mind is perfectly sound when its faculties are exercised on any subjert un- connected with a particular impression which con- stitutes the entire disease. Cases arc on record which, if faithfully recorded, fully come up to this description. In general the real character of mo- nomania is very different. The feelings and affec- tions are in that state which has been described under the head of moral insanity, and on this it would appear that some hallucination or maniacal delusion has supervened. The following case will serve to illustrate the observation which we have just made. Mr. E. W-----, a gentleman about thirty vears of age, has laboured for several years under symp- toms of moral insanity. He has been Ions de- jected in spirits and morose in temper, dissatisfied with himself, and suspicious of all that surrounded him. He was capricious and unsteady in his pursuits, frequently engaging in some new study INSANITY. 35 'n the most sanguine manner, and soon abandon- ing it in despair of making any progress, though possessed of good talents and considerable acquire- ments of knowledge. He passed the requisite period of time at one of the Universities, but could not be prevailed upon to go in for his de- gree, either through timidity and want of resolu- tion, or, as it was conjectured by his friends, from a morbid apprehension that the examiners would not deal fairly with him and award him the station to which he aspired and believed himself entitled. He applied himself afterwards to the study of medicine, and then to that of metaphysics, and speedily relinquished both. He frequently changed his residence, but soon began to fancy himself the object of dislike to every person in the house of which he became the inmate. His peculiarities appearing to increase, he was visited by two phy- sicians, who were desired to investigate the nature of his case. On being questioned narrowly as to the ground of the persuasion expressed by him, that he was disliked by the family with which he then resided, he replied that he heard whispers uttered in distant apartments of the house indica- tive of malevolence and abhorrence. An obser- vation was made to him that it was impossible for sounds so uttered to be heard by him. He then asked if the sense of hearing could not, by some physical change in the organ, be occasionally so increased in intensity as to become capable of affording distinct perception at an unusual dis- tance, as the eyes of mariners are well known to be accommodated by long effort to very distant vision. This was the only instance of what might be termed hallucination discovered in the case after a minute scrutiny. It seemed to be a late suggestion. The individual had been for years labouring under a gradually increasing moral insanity. His judgment had become at length perverted by the intensity of his morbid feelings, and admitted as real an erroneous im- pression, suggested by his fancy, which happened to be in harmony with his feelings, and served to account for them. There are, indeed, cases of insanity attended with hallucination on a constant erroneous im- pression, in which this system will appear to many persons to afford but little evidence as to the real nature of the complaint. The delusive impression appears to be so blended with the pre- valent disorder of the feelings and affections, or it seems to be so much the result of the peculiar cir- cumstances by which the patient is surrounded, that it is scarcely contemplated as a distinct and peculiar phenomenon. These remarks will re- ceive illustration from the following case. Mr. H. P---- had been for many years con- fined in a lunatic asylum, when, an estate having devolved upon him by inheritance, it became ne- cessary to subject hiin anew to an investigation. He was examined by several physicians, who were unanimous in the opinion that he was a lunatic; but a jury considered him to be of sound understanding, attributing his peculiarities to eccentricity, and he was consequently set at liberty. The conduct of this individual was the most eccentric that can be imagined: he scarcely per- formed any action in the same manner as other men ; and some of his habits, in which he obsti- nately persisted, were singularly filthy and dis- gusting. For every peculiar custom he had a quaint and often ludicrous reason to allege, which indicated a strange mixture of shrewdness and absurdity. It might have been barely possible to attribute all these peculiarities, as well as the morbid state of temper and affections, to singu- larity in natural character and to the peculiar cir- cumstances under which this person had been placed. But there was one conviction deeply fixed on his mind, which, though it likewise might be explained by the circumstances of bis previous history, seemed to constitute an instance of maniacal delusion. Whenever any person whom he understood to be a physician attempted to feel his pulse, he recoiled with an expression of horror, and exclaimed, " If you were to feci my pulse, you would be lord paramount over me for the rest of my life." The result has proved that confinement is not always necessary in cases of this description. Mr. H. P-----has remained at liberty for many years, and his conduct, though extremely singular, has been without injury to himself or others. We shall conclude our observations on this subject by the record of a remarkable case which illustrates the tendency of moral insanity to de- generate into, or ultimately assume, the character of monomania. The individual who was the subject successively of these forms of disease, was for several years in a state which gave rise to ap- prehension in many of his friends, while some who narrowly observed him were fully convinced of his insanity. The disease at length broke out in a form which admitted of no doubt. A gentleman remarkable for the warmth of his affections, and the amiable simplicity of his cha- racter, possessed of great intellectual capacity, strong powers of reasoning, and a lively imagina- tion, married a lady of high mental endowments, and who was long well known in the literary world. He was devotedly attached to her, but entertained the greatest jealousy lest the world should suppose that, in consequence of her talents, she exercised an undue influence ever his judg- ment, or dictated his compositions. He accord- [ ingly set out with a determination of never con- sulting her, or yielding to her influence, and was always careful, when engaged in writing, that she should be ignorant of the subject which occupied his thoughts. His wife has been often heard to lament that want of sympathy and union of mind which is so desirable in married life. This pecu- liarity, however, in the husband so much in- creased, that in after years the most trifling pro- position on her part was canvassed and discussed by every kind of argument. In the meantime he acquired strange peculiarities of habits. His love of order, or placing things in what he considered order or regularity, was remarkable. He was continually putting chairs, &c. in their places; and if articles of ladies' work or books were left upon a table, he would take an opportunity unob- served of putting them in order, generally spread- ing the work smooth, and putting the other articles in rows. He would steal into rooms belonging to other persons for the purpose of arranging the various articles. So much time did he consume 36 INSANITY. in trifles, placing and replacing, and running from one room to another, that he was rarely dressed by dinner-time, and often apologised for dining in his dressing-gown, when it was well known that he* had done nothing the whole morning but dress. And he would often take a walk in a winter's evening with a lanthorn, because he had not been able to get ready earlier in the day. He would run up and down the garden a certain number of times, rinsing his mouth with water, and spitting alternately on one side and then on the other, in regular succession. He employed a good deal of time in rolling up little pieces of writing-paper, which he used for cleaning his nose. In short, his peculiarities were innumer- able, but he concealed them as much as possible from the observation of his wife, whom he knew to be vexed at his habits, and to whom he always behaved with the most respectful and affectionate attention, although she could not influence him in the slightest degree. He would, however, oc- casionally break through these habits ; as on Sun- days, though he rose early for the purpose, he was always ready to perform service at a chapel a mile and a half distant from his house. It was a mys- tery to his intimate friends when and how he prepared these services. It did not at all surprise those who were best acquainted with his pecu- liarities, to hear that in a short time he became notoriously insane. He fancied his wife's affec- tions were alienated from him, continually affirm- ing that it was quite impossible she could have any regard for a person who had rendered him- self so contemptible. He committed several acts of violence, argued vehemently in favour of sui- cide, and was shortly afterwards found drowned in a canal near his house. It must not be omitted that this individual derived a predisposition to madness by hereditary transmission : his father had been insane. Of Mania.—The phenomena of mania in its ordinary form are very distinguishable from those of monomania. The aspect, the voice, the ges- tures of the lunatic in the active state of maniacal derangement, form a contrast with the retired and morose habits of the sullen monomoniac. In cases, however, of mania, distinctly so termed, one im- pression often occupies the mind of the individual for the time being, and this is frequently some hallucination respecting his own person, some inagnific dream of self-importance and superiority. M. Pinel says, " I was frequently followed at the Bicetre by a general, who said that he had just been fighting an important battle, and had left fifty thousand men dead on the field. At my side was a monarch who talked of nothing but his subjects and his provinces. In another place was the prophet Mahomet in person, denouncing ven- geance in the name of the Almighty. A little further was a sovereign of the universe, who could with a breath annihilate the earth. Many of them seemed to be occupied by a multiplicity of objects, which were present to their imagina- tions. They gesticulated, declaimed, and vocife- rated incessantly, without appearing to see or hear anything that passed. Others, under illusive in- fluence, saw objects in forms and colours which they did not really possess. Under the influence of an illusion of that kind, was a maniac who mistook for a legion of devils every assemblage of people that he saw. Another maniac tore hii clothes to tatters, and scattered the straw on which he lay, under the apprehension that they were heaps of twisted serpents." Ordinary mania, or madness affecting the mind with a general disturbance of the intellectual fa- [ culties, is sometimes preceded by occasional fits of excitement and confusion, in which the under- j standing is hurried and disordered. But it differs 1 from monomania in making its attacks for the most part suddenly and without any premonitory symptoms. An individual, after having undergone an unusual degree of mental and bodily exertion and fatigue, after a fit of intoxication, which in this country is one of the most ordinary of ex- citing causes of madness, after the excitement of violent passions or anxieties, after exposure to cold and the inclemencies of weather, passes sometimes a day or two in a state of feverish disorder and general uneasiness, and two or three restless nights. His mind is then found to be confused ; he appears scarcely to know what he says, talks nonsense, repeats his words frequently, expresses his feelings with an absurd degree of warmth and enthusiasm, cries, laughs, utters rapid and confused sentences in a hurried and impetuous manner. " In the course of a few days, or sometimes at first, he is seized with violent agitations, expresses vague and continual apprehensions, is subject to fits of terror; he is in a state of constant excitement and sleep- lessness ; he indicates the troubled state of his mind by unusual gestures, by singular appearances of the countenance, and by actions which cannot ! fail to strike in a forcible manner every observer. I The various aspects which the symptoms of the disease assume at this period, have never been more graphically described than by M. Pinel. and his looks fixed on high; he speaks in a low voice, or utters cries and vociferations without any apparent motive; he walks to and fro, and some- times arrests his steps as if excited by the senti- ment of admiration, or wrapt up in profound re- verie. Some insane persons display wild excesses of merriment, with immoderate bursts of laughter. Sometimes, also, as if nature delighted in contrasts, gloom and taciturnity prevail, with involuntary showers of tears, or the anguish of deep sorrow, with all the external signs of acute mental suffer- ing. In certain cases a sudden reddening of the eyes and excessive loquacity give presage of a speedy explosion of violent madness, and the ur- gent necessity of a strict seclusion. One lunatic, after long intervals of calmness, spoke at first with volubility, he uttered frequent shouts of laughter, and then shed a torrent of tears; experience had taught the necessity of shutting him up immedi- ately, for his paroxysms were at such times of the greatest violence. It is often observed that extatic visions in the night are the preludes to fits of ma- niacal devotion; and by enchanting dreams, or by the fancied apparition of a beloved object, it some- times happens that erotic madness breaks out with violence, when it may either assume the character of a calm reverie, or display nothing but extreme confusion in the ideas and the entire subversion of reason." When the disease has taken a firm hold on its INSANITY. 37 unfortunate victim, it sometimes gives rise to all ' and imperfect ideas becomes after a time so rapid the internal effects, and displays all the external as to preclude distinct utterance. The association phenomena which the most intense feelings of which connects images in the mind seems to be human misery, resulting from the real calamities lost, or at least cannot be traced, and the thoughts of life, may be imagined to produce. The maniac ] appear to be single and insulated. Words and who becomes the subject of violent excitement " is sentences are half pronounced; the voluntary seen in a state of extreme agitation, with his face j movements are without design, and the effort to flushed, his eyelids inflamed, and his eyes sparkling, i perform them is incomplete ; it is impossible to fix his temples beating violently; he talks, cries, sings, the attention of the patient sufficiently for obtain- grieves, gets into fits of rage by night and by day, ing a reply to the shortest question ; he becomes and is incapable of taking rest. The melancholic, ' almost insensible to the existence of external ob- also, in extreme agitation, but wrapt up in himself, j-jects, talks incessantly, or repeats the same word goes to seek in some quiet and dark recess a re- ! or half sentence over to himself; he takes his food, fuge from his panic terrors, from his gloomy and when it is offered to him, by hasty snatches, and despairing thoughts ; or the means of putting into swallows it greedily, or spits it out again in order to execution his baneful designs. The insensible continue his unmeaning jargon. After this state and stupid, incapable of anything, remain un- ! of excitement has continued for some time, it gra- conscious of surrounding objects, and do not even dually subsides, and the disease either continues exert themselves to satisfy their most urgent wants, At this period of madness there is a constant want of sleep : the patient often experiences a feeling of tension and of heat in the head, without, how- ever, complaining of it. Sensibility to external impressions, as well as to all bodily changes, is so much lessened, that blisters, cauteries as well as exposure to intense cold, will sometimes produce but little expression of pain or distress. 4. Of Incoherent Madness.—A very peculiar and well characterized form of mental derange- with mitigated violence, but still with the same form of incoherency and want of connection in the course of thoughts and feelings, or the expres- sions gradually appear to be more connected, the patient becomes capable of sleep, and a slow pro- gress towards the restoration of the reasoning fa- culty is perceptible. The writer of the present article has witnessed several instances of complete recovery of the mental powers after the existence, during many weeks and even months, of maniacal phenomena answering to the above description ; mentis that of incoherent madness, or incoherency, j and every physician who has had opportunities of in which the mind is occupied by a rapid succes- : inspecting lunatic asylums must have observed sion of unconnected thoughts and evanescent emo- many cases in which the state of incoherency has tions, and becomes entirely incapable of reflection, terminated in recovery, and others in which it has or even of distinct apprehension. Such cases are , become chronic and permanent. frequent, and are to be met with in every recep- I The following case described by Pinel is a well tacle containing a considerable number of lunatics. , marked instance of the morbid state now under Incoherent madness, or incoherency, is the most i consideration, and it will be sufficient to prove proper designation for this state of disease, as it that the affection termed by that writer demence describes the essential and characteristic feature, is precisely what we have designated as incohe- By Pinel the term demence, or dementia, has been rent madness. adopted ; and to this there would be no objection ( " An ardent but ill-informed patriot, and one of if it were not for the circumstance that the same | the warmest partisans of the celebrated Danton, term has been used by Esquirol and Georget with was present at the sitting of the legislative body, a different meaning, and that confusion would when the writ of accusation was pronounced hence arise from an ambiguous designation. Under against that deputy. He withdrew in consterna- the term demence, the writers last mentioned de- ' tion and despair, shut himself up in his own scribe that state approaching to fatuity or idiotism, ! apartment for several days, and surrendered him- which is the termination of protracted insanity, , self to the influence of the most gloomy ideas. and in this sense the word is now commonly re- 'What! Danton a traitor !' he repeated without ceived. Since this is a morbid condition very ceasing; ' then is there no man to be trusted ; the distinguishable from that incoherency which is a republic is lost!' His appetite and sleep forsook primary and idiopathic form of mental derange- . him. Complete insanity ensued. Having under- ment, each of these states of disease must have a . gone the usual treatment at the ci-devant Hotel particular epithet. j Dieu, he was removed to the Bicetre. He passed This form of madness is in some instances a several months in the infirmary of this hospital primary affection ; at least the tendency to inco- herency displays itself very early in the progress of the case. The disease commences with great excitement; the patient is restless and unusually active ; his manners are full of bustle and violence; his countenance flushed; he has sleepless nights; in a state of tranquil reverie, uttering incessantly half expressed and unconnected sentences. He talked alternately of daggers, sabres, dismasted vessels, green meadows, his wife, his hat. He never thought of eating but when food was actually put into his mouth; and in respect to his func- his thoughts follow each other with turbid rapidity; tions he was almost levelled with an automaton.1 and his whole appearance strongly resembles that j The chronic form of incoherence presents simi- of a man of excitable temperament intoxicated lar phenomena, but in a milder degree. Patients with wine or spirituous liquors. In many cases in this last state have intervals of rest; they there is no hallucination or erroneous impression sleep, and have periods of tranquillity during their on the mind that can be traced, but the violent waking hours, but seldom or never display cohe- and irrational activity of the patient is such as to rence and arrangement in their ideas, or make require coercion. The succession of confused any approach towards a sane and vigorous use D INSANITY. of the reasoning powers. Neither have they any appearance of melancholy or abstraction, but they are capable of being momentarily excited by ob- jects which impress their senses and by the scenes around them, though their impressions are transi- tory and evanescent. They talk to themselves or to others for a long time in phrases scarcely con- nected by any perceptible link, and in which there is rarely a glimpse of meaning; and if any asso- ciation can be traced in their thoughts, it is of the most trivial kind, and depending on a word or some sensible object which for a moment attracts their attention. Tbey will sometimes repeat the same word or half sentence many times, but soon forget it. The disease which we have now described under the designation of incoherent insanity has been by some writers identified with dementia, or the first stage of fatuity. It is, however, a particular form of mental disease, assuming its peculiar character from the first, and displaying phenomena very different from those of dementia, though, like other forms of madness, it is liable, when long pro- tracted, to pass eventually into fatuity. The writer of this article has seen in private practice and in hospitals several well-marked cases of incoherent madness in the acute form, which ran their course and terminated in recovery without passing into the chronic stage. Of the chronic form, which approaches most nearly to dementia, but may yet be distinguished from that state of disease in its ordinary appearances, some illustrative cases have been pointed out to him in the Lunatic Asylum at Fishponds, near Bristol, by Dr. Bompas, the hu- mane and intelligent conductor of that establish- ment. Two of these occur in brothers, whose symptoms are very similar, though those of one are more strongly marked than of the other. Al- though the former of these individuals has been in confinement for many years, his countenance does not display the well-marked aspect of dementia, of which M. Esquirol has given so excellent a delineation. If questioned, he replies with an in- telligent look, but in words quite beside the sub- ject, and chatters about a hundred unconnected things in the course of a few minutes. If you re- peat the question, it only increases his volubility without apparently drawing his attention a whit more nearly to the subject of inquiry. 5. Observations on the State of the Faculties in Madness.—It has been a question frequently agitated among medical writers, in what precise changes in the organic operations of the brain, as well as in the mental processes which result from these operations, madness consists. The present is not a suitable opportunity for entering into a full discussion of this subject. In a practical point of view, all that is requisite will be obtained by a brief inquiry into the actual condition of the intel- lectual faculties in insane persons. It may be observed that consciousness generally remains unimpaired in lunatics, though its exer- cise, in some cases of madness with hallucination, is connected with singular phenomena. The pa- tient is conscious of his sensations, but he some- times expresses himself as if his notion of personal identity were strangely confused. He talks and reasons about his feelings as if they were those of another individual. These are by no means frequent cases, and in general Im-^*'™/ ^ tinct perception of their personal .dentty ami refer their sensations and ideas correctly to them- SC Sensation likewise remains unimpaired in the insane : the organs of sense at least are not the seats of disease, nor are those processes in the ner- vous structure on which sensation depends in a i deranged state. The sensations produced by light and sound are sometimes morbidly acute, from temporary affection of the organs of sight and hearing; but this is accidental, and by no means a circumstance characteristic of madness. The effects of cold and other painful impressions are j in some instances disregarded by lunatics, but this i seems to be merely a result of intense excitement of the mind and its direction to other feelings and operations. Such cases are not so frequent as I they are supposed to be, and in general lunatics I are sensitive of external impressions. Perception of external objects is generally un- j impaired, but in some cases it is strangely affected and perverted by the morbid impressions on the mind, audi by the influence of the prevailing hal- lucinations. Maniacal hallucinations are of two kinds. Dr. Cullen has remarked that " there is sometimes a false perception or imagination of things present that are not; but this is not a constant nor even a frequent attendant of the disease. The false judgment is of relations long before laid up in the memory." This means that the hallucination sel- j dom refers to the scene actually present, but to the | impressions of memory. When, however, the maniacal reverie becomes very intense, it produces I hallucinations or false impressions which represent ' unreal objects as actually present. Even in this case it does not appear that perception is impaired. I Some particular phantasms, the creations of reve- i rie, are presented to the mind in colours so vivid as to produce an effect similar to that of actual perception ; the patient in other respects makes no mistakes with regard to place or time; his per- ceptions of external objects are correct and uni- form whenever his attention is directed to percep- tible things; but he is so intent upon his reverie, that for the most part he totally neglects them; his fancy becomes so intense in its operation as to carry him away from the influence of his external perceptions, and to environ him with visions of unreal scenes. [ We have often seen a lunatic under this form of disease walk up and down a frequented place, sufficiently alive to external objects to avoid falling in the way of horses and carriages, or running against foot-passengers, but so intent upon the scene presented by his excited imagination as to be busily employed in issuing commands to troops of which he imagined himself to be the general, | and in directing them to enfilade to the right and left, and perform a variety of evolutions. All this ■ he performed with a voice and gesture that were | perfectly natural and consistent with reality. To , this modification of madness belong those mania- cal hallucinations termed by some writers idilo- i mania or dsenionomania, in which the lunatic fan- cies that he sees and holds converse with imagi- nary beings. The conception of the mind is °so i vivid and intense that it withdraws consciousness INSANITY. entirely from the sensations excited by surround- ing objects, which nevertheless exist, and occa- sionally under particular circumstances give rise to perception. Maniacal hallucinations have, however, a much firmer hold on the belief in some cases of madness than the strongest evidence af- forded by perception, and hence the futility of those projects which are occasionally suggested for surprising lunatics into a conviction of their false judgments. An insane female confined in an asylum had a firm persuasion that her husband was dead. When he came to visit her, she as- serted that it was the devil who had assumed his form. Her recollection and perception had re- mained unimpaired, but the insane hallucinations overcame their evidence and held possession of her mind. The power of reasoning or judgment does not appear to be so much impaired in madness as the disposition to exercise it on certain subjects. Of- ten there is a manifest unwillingness to admit any evidence unfavourable to the false notions impressed upon the mind, while great ingenuity is displayed in finding arguments which may tend to make it apparently more reasonable. A case illustrative of this remark has been already mentioned. In many instances of madness it would appear that the characteristic feature of the disease is a morbid inclination to indulge in reverie, and to yield the judgment and all the faculties to its con- trol. The impressions of reverie are so modified by disease as no longer to be distinguishable from those of memory or active reflection. We may venture to say that this observation will go far towards explaining the mental phenomena of the disease. 6. Disorders in the state of the physical func- tions attendant upon madness.—The phenomena of madness which attract most observation, and which indeed characterize the disease, are those which depend upon the disordered state of the ce- rebral functions ; but other processes in the living body are likewise in a state of derangement. There is in most cases of insanity, besides the morbid condition of the brain and nervous system, more or less of disturbance in the physical functions ; the secretions, excretions, appetite, and digestive pro- cesses are frequently disordered. Medical writers have differed in opinion as to the relation which these affections bear to the cause of insanity.— Pinel has stated it to be the result of his inquiries that the primary seat of mental alienation is gen- erally in the region of the stomach and intestines, and that from that centre it propagates itself, as it were, by irradiation, and deranges the understand- ing. Others have looked upon the disorders in the functions of the viscera as merely contingent results of a primary disease, seated in or immedi- ately affecting the brain. Whichever of these opinions may be correct, the general, or at least the frequent co-existence of disorder in the physical functions with that affection of the brain from which the deranged state of the mind immediately results is an indis- putable fact. The physical functions are differently affected in different forms of madness. In disorders of slow and gradual accession, and especially in those cases in which the mind is melancholy and de- pressed, a torpid state of the vital and natural functions for the most part prevails; the circula- tion is languid; the pulse weak and generally slow; the extremities cold; the skin cold and clammy ; most of the secretions are defective ; the bowels are torpid and sometimes obstinately con- stipated and flatulent, requiring strong doses of aperient medicine. The appetite is defective; di- gestion is impaired ; sometimes there is a constant loathing of food, which, if the patient were not obliged to eat, would induce hitn to starve him- self, and it is often extremely difficult to persuade persons in this state to swallow nutriment suffi- cient for the preservation of life. Emaciation and loss of strength inevitably result from these cir- cumstances, but they are sometimes not so striking as any person would anticipate. Attacks of maniacal disease, which break out suddenly with great excitement of the passions, with general disturbance of the intellectual facul- ties, or with incoherence, are almost always ac- j companied by symptoms of fever or pyrexia more ! or less acute. The pulse is rapid, often full, and j beating with disproportioned strength in the carotid and temporal arteries; the skin is hot and | the tongue white; there is thirst, with loss of ap- petite, headach, sleeplessness, and great irritabili- | ty ; the secretions are deficient, the urine is high- coloured and scanty, and the bowels are consti- pated. The face is often flushed ; the eyes are I glossy and suffused ; the conjunctiva is injected with blood, and the pupils are contracted. The patient sometimes complains of pain in the fore- head and temples, with a sense of weight upon I the head, or of constriction, as if the scalp were tightly drawn. It has been observed that in some I instances persons who had previously suffered 1 severely from headach have ceased to complain of ! it when madness has supervened, and that it has returned when such patients have become con- valescent. Want of rest is often a troublesome and distressing symptom. Many patients pass whole nights without closing their eyes, or when they obtain sleep, it is short and agitated. In other instances a few hours of sound sleep are the prelude to a paroxysm of renewed excitement, the maniacal symptoms breaking out on waking ! with increased violence. I All the symptoms which refer themselves in a i perceptible manner to the head are liable to un- [ dergo occasional exacerbations during the con- ; tinuance of madness. Increased heat of the scalp, redness of the eyes, fulness and strong pul- sation of the carotid and temporal arteries, want of sleep and consequent irritability of the temper and feelings, indicate and precede or accompany renewed periods of violence in the symptoms of mental derangement. In many instances of maniacal disease there is much disturbance in the functions of the intestinal canal. This observation has been made more par- ticularly in persons whose general health has [ been previously much neglected; in the inmates j of some lunatic asylums; in individuals of the | lower class, who have been subjected to hardships I and unwholesome diet, as well as to cold and a 40 INSANITY. damp unwholesome atmosphere ; in cases in which the disease has followed excesses of various kinds, or confinement on ship-board, with the use of salt provisions. In many instances of this description it has been found that the bowels had been long in a confined and torpid state. In those instances in which it is stated that the bowels are open and even more loose than natural, it often appears on further examination that a long-continued torpor and constipation have given way to diar- rhoea ; the abdomen, which had previously been swelled with indurated matter, has become more distended than before, flatulence being added to the load of solid contents but partially discharged. The evacuations are thin and watery, or contain mucus mixed with vitiated bile and recent aliment in an undigested state. Sharp and transient pains are experienced in various parts of the ab- domen, which is often tender on pressure ; at length, in very neglected cases, dysentery super- venes and brings on extreme emaciation. The tongue is often red or covered with a brown fur, and the mouth and fauces with a viscid mucus, which, together with saliva, the patient spits out in all directions. There is great thirst and a peculiar fetor of the breath, which extends to the whole person. The appetite is depraved ; in many cases the patient has an aversion to all food; in other instances he has a keen and voracious desire for it, and greedily devours without selection every thing eatable that falls in his way. The skin is cold; there is a remarkable coldness of the extremities, resulting from the damp state of the skin and a want of energy in the circulation through the extreme vessels. In some cases of long duration, there are papular or scaly erup- tions ; and in exhausted and debilitated subjects, furunculi appear in various parts of the body which are much disposed to slough. [See an interesting case, by Dr. Prichard, of the connection of insanity with tuberculous forma- tions and ulceration in the intestinal canal, in Provinc. Med. Journal, Jan. 27th, 1844, or in Amer. Journal of the Med. Sciences, April, 1844, p. 44£] 3_, Cases of madness, coming on with some degree of rapidity, are often preceded and sometimes accompanied or followed by suppressions of natural or customary discharges, by the disappearance of external diseases, or the cure or suspension of internal complaints. The relation which these changes bear to madness as causes or results may be different in different cases; they are connected sound state of mind, though not to complete bodily health. „«,„«*„ Skct HI —Of the Dnration of Insanity, and of the Modes of its Termination. The duration of insanity is various, and admits of no general estimate. In some instances this disease has subsided in the course of a few days after its commencement; in others it continues for many years. M. Esquirol has remarked that it is not uncommon to meet with inmates of lunatic asylums who have been twenty, thirty, or even forty years in confinement. The same observa- tions must have occurred to every person who has been in the habit of visiting such establishments. Insanity has three different terminations:— first, in recovery; secondly, in a state of fatuity, or of chronic and permanent failure or obliteration of the mental faculties; thirdly, in death. The last is generally the contingent result of some of those disorders in the physical functions of the body to which the insane are especially liable. We shall allot a separate consideration to the cir- cumstances connected with each of these events of insanity. 1. Of Recoveries from Insanity.— Recovery from madness sometimes takes place suddenly, but more frequently it is gradual, and preceded by several periods of mitigation in the intensity of disease, and often by lucid intervals. The prospect of recovery is much greater in young persons than in those of advanced years, and it diminishes, other circumstances being equal, with the patient's age. M. Esquirol has observed that few lunatics are cured after the sixtieth year. It must, however, be taken into the account that few comparatively are for the first time attacked by madness after that period of life. The curability of madness, or, to speak more correctly, the proportion of maniacal cases which terminate in recovery, is likewise subject to great variation from circumstances which refer to the nature of the disease, its occasional complication with other maladies, the sex and constitution of the patient, the mode of treatment to which he is subjected, and the causes which have given rise to his disorder; and hence any general calcu- lations on this subject are matters rather of cu- riosity than of practical value. One remark, how- ever, may be of use, as it may encourage medical practitioners in their efforts to remove or mitigate the disease. Of cases which present no peculiarly unfavourable combinations, a much larger propor- tion terminate in recovery than is generally sup- circumstances of that disease. The catamenia, I posed, or than any person could be led to believe if not suppressed previously to the manifestation of cerebral disorder, soon become scanty, or cease entirely after its actual appearance. Lochia? and other analogous effluxes are suppressed; ulcers, which had become habitual and had long dis- charged, are dried up; chronic eruptions generally from the inspection of reports from hospitals. In these reports it generally happens that a great number of inveterate cases, and of such as arc incurable from their conjunction with other dis- eases dangerous to life, and indicating changes in the organic condition of the brain, are blended with disappear, or are materially lessened ; symptoms those of simple insanity in the generaUverages; of pulmonary phth.s.s in various stages cease or | M. Esquirol has endeavoured, by comparing the become mitigated in a remarkable degree. On the decline of maniacal disease, it is often found that the return of such discharges, or the revival of suspended trains of morbid symptoms such as we have described, is the harbinger of restoration to a reports of several extensive hospitals in France and England, to throw some light on the cura- bility of madness, or on the proportion of reco- veries. The following table presents some facta which are of great interest. INSANITY. 41 TABLE OF RECOVERIES FROM MADNESS. In England. Admissions. In Bethlem Hospital..............from 1748 to 1794 ____ 8874 . .............. in.......1813 ____ 422 . In St. Luke's....................from 1751 to 1801 ____ 6458 . In York Asylum.............................\.......... 599 In the Retreat, near York..........from 1801 to 1814 ____ 163 . Totals.. 16516 In France. ------ Charenton................from Nov. 22, 1798 to 1800, 22 July 97 1803............ 499 SalpeHriere.......................from 1801 to 1805 ____ 1002 .......................from 1804 to 1813 ____ 2005 " .......................from 1806 to 1807 ____ 531 " ......................from 1812 to 1814 ____ 891 In M. Esquirol's private establishment, from 1801 to 1813 .... 335 5918 Totals.. 5360 2691 From the data contained in this table, M. Es- quirol concludes, « first, that the absolute number of recoveries from madness is about one in three; secondly, that the number of recoveries varies from one in four to one in two, or to one-half of the number of persons affected: this difference depends upon particular circumstances of locality, on the nature of the cases, and of the treatment pursued .- thirdly, that cures are more numerous in France than in England." He adds that they are much more rare in Germany and in Prussia. A much more extensive collection of reports from various lunatic asylums, both public and private, in England, France, and other countries, has been made by Dr. Burrows, who has con- structed from these materials a table exhibiting the proportion of recoveries. The evidence afforded by such collections is very much confused, and in many instances rendered wholly inconclusive from the variety which exists in the regulation of differ- ent establishments as to the nature of the cases admissible into them, and the time during which the patients admitted are kept. For instance, the hospitals of Bethlem and St. Luke impose cer- tain exclusions elsewhere unknown. They reject all patients who have been more than twelve months insane; those affected by paralysis, how- ever slight, and by epilepsy or convulsive fits; idiots, the aged and infirm; those discharged un- cured from other hospitals: there are likewise other exclusions besides those above mentioned, and all persons who have not recovered at the ex- piration of one year are dismissed. Yet on com- paring the reports of these hospitals with those of other institutions, the regulations of which are less favourable to a high proportion of cures, and where no selection or exclusion exists, we do not find, as Dr. Burrows remarks, the relative number of recoveries to be so great as might be expected. It is indeed surprising to find that the reports of Bethlem Hospital, of a century and a half ago, give a greater proportion of cures than those of many years preceding 1817, when an improve- ment took place in the arrangements of that es- tablishment. Dr. Burrows remarks on the au- thority of Stow, who derived his information from Dr. Tyson, physician to Bethlem Hospital, that " from 1684 to 1703, 1294 patients were admitted, of whom 890 were cured, which is a proportion Vol. III. —6 » • of two in three. But from 1784 to 1794, 1664 patients were admitted, of whom 574, or rather more than one in three, recovered." It is proba- ble that there were circumstances in the former arrangements which, if they were known, would explain this difference. On the whole, the results of Dr. Burrows' inquiries are much more favoura- ble to British hospitals than those of M. Esquirol. It appears, indeed, from his statements that the pro- portions of recoveries in England are greater than those obtained in France, Germany, and, a for- tiori, in any other country in Europe. This may be in some degree judged of by comparing the follow- ing statements, taken during late years, with those previously given from M. Esquirol's collections. In Stafford Asylum, from 1818 to 1828, ad- missions 1000; cured 429 ; or about 43 in 100. In Lancaster County Asylum, from 1817 to 1825, admissions 812; cured 322 ; or about 39 in 100. In Wakefield County Asylum for the West Riding of Yorkshire, from 1819 to 1826, admis- sions 917; cured 384 ; or about 42 in 100. [The experience of the insane institutions of the United States has been highly encouraging. They are admirably conducted institutions; yet it is not easy to deduce from them, or from the European institutions more than an approximation to the number of cures. Annual reports are cer- tainly not well adapted to convey very positive information as to relative curability ; and this is sufficiently shown by the discrepancy amongst them ;—those which publish the smallest number of cases cured being by no means the least suc- cessful. The published ratio of cures is generally, indeed, higher than it ought to be, owing to the time being too short to enable an accurate judg- ment to be formed, and the patients being too often withdrawn or dismissed from the institution before they were wholly restored. Dr. Pliny Earle (Amer. Journal of the Med. Sciences, April 1843, p. 347) has drawn up the following table, which applies, in the case of all the institutions but one, to a series of years. In the Bloomingdale Asy- lum, New York, many cases of delirium tremens are received, which may account for the greater proportion of recoveries among males;—as a gene- ral rule, the greater number of restorations ap- pearing to occur in the other sex. 42 isrioMS, llanwell ........•........ Pennsylvania Hospital..... Blooiningdale............ Massachusetts State Hospital Total................... INSANITY. TIME. 7831 to 1840 1841 1821 to 1841 1833 to 1841 — 1 w oi* e y. Per Cent Admitted Cured. Per C-i.l. 20.01 ""ToTo* 226 22.24 14.56 | 73 15 20.54 50.12 ! 906 352 38.91 53.67 637 39^2 61.53 35.09 2632 985 35.80 ;, »„v» nlarp in the first month of its duration, (See, also, Dr. Woodward, in Eleventh Annual j ness take place in tn ...... . .. . ; -i itr..~**e. the recoveries dun those of succeeding months Report of the State Lunatic Asylum, at Worces tcr, Mass., p. 39. Boston, 1844.)] From these statements it clearly appears that M. Esquirol's computation of recoveries is much below what really takes place under favourable circumstances. The results are so different under different circumstances, that no general average can be of much value in a practical point of view. Another inquiry, which admits of a more satis- factory elucidation, and which leads to results very interesting in their relation to prognosis, re- fers to the period of the disease during which re- covery is chiefly to be expected. Some facts, tending to illustrate this question, were contained in a memoir presented by M. Pinel to the French Institute in 1800. It appeared from this memoir that the greatest number of recoveries from mad- ness take place in me ■■»> —«..-» — ---, the recoveries during the first being compared wnh those of succeeding months. The mean time for the duration of the disease, in cases terminatini favourably, was fixed in the same document at from five to six months. This result was deduced from a selection of cases from which the author excluded all those which had been under previous treatment, as well as cases of long duration. A longer term is assigned to this disease, in cases terminating in recovery, by Mr. Tuke in his ac- count of the Retreat at York; and M. Esquirol, whose accuracy of research in subjects of this na- ture gives to his authority the highest value, con- firms the opinion of Mr. Tuke. He has drawn this conclusion from a statement of the cases ad- mitted into the Salpetriere during ten years, u shown by the following table. TABLE OF Admissions. 209..... 206...... RECOVERIES 1804. 1805. 1806. 64 . . 47 . . 7 ....... 73 . . 54 ...........78 AT THE SALPETR] 1E07. 1808. 1809. 1810. . 4.. 3.. 2 ..... . 4.. 2.. 2.. 1. . 49 . . 10 . . 3 . . 1 . . 60 . . 55 .. 11 . . 1 . ......64 . . 57 . . 4 . ERE 1811. 1 . DURING 1812. 1813. 1..... TEN 1814. YEARS. Totals of Cures. .. 129 1 . . 2 . . 3 . . 3 . . 3 . . 11 . . 49 . .. 137 . 1 . . 2 . 9 . 51 . 44 . . 1..... 2..... 1..... 4 .. 1 . 7 .. 1 . 30 . . 8 . 75 ...41 . ......50 . .. 143 204..... .. 129 .. 130 ...........48 . . 64 . .. 129 .................48 . .. no 85 .. 127 .. 99 ...1218 It seems that the report on which this table was founded, extended from the year 1804 to 1813; 2804 female lunatics were admitted during this interval, of whom 795 were considered as incur- able, on account of their advanced age, or because they were idiotic, epileptic, or paralytic subjects. The remaining 2005 were put under treatment without regard to the duration or peculiar charac- ter of their disease. Out of this number, 604 were cured during the first year, 497 in the second, 86 in the third, and 41 in the seven succeeding years. From these data M. Esquirol draws the following conclusions; first, that the greatest num- ber of recoveries are obtained in the two first years; secondly, that the mean duration of cases that are cured is somewhat short of one year; thirdly, that after the third year the probability of cure is scarcely more than one in thirty. There are, nevertheless, examples which prove that we ought never to despair of the recovery of lunatics. M. Pinel, from Baumes, cites the case of a lady who passed twentv- five years in a state of lunacy, within the know- ledge of the whole country where she lived, and who suddenly recovered her reason. " I have seen," •ays the same writer, « a girl who from the age of ten years was in a state of dementia, with suppression of the catamenia. One day, on rising from bed, she ran and embraced her mother, ex- claiming, 'Mamma! I am well!' The catame- nia had just flowed spontaneously, and her reason was immediately restored. Such facts are rare, but they serve to prove that from the duration of the disease alone there is no reason to despair al- together of recovery." [See the work of M. Esquirol, Des Maladies Mcntules Paris, 1838.] A few instances of the same kind have occurred in several lunatic houses or public hospitals, from ! the superintendents of which the writer of this article has obtained information respecting them. i From another table published by M. Esquirol, it appears that, out of 269 maniacal patients, 27 were cured in the first month of their illness, 34 in the second, 18 in the third, 30 in the fourth, 24 in the fifth, 20 in the sixth, 20 in the seventh, 19 in the eighth, 12 in the ninth, 13 in the tenth, 23 after the first year, and 18 afier two years. j This is perhaps an attempt at a greater degree of accuracy in calculation than is, from the nature , of circumstam es, attainable The same writet ; has made a remark in illustration of the greater INSANITY. 4tf proportion of recoveries observed in the early pe- riod of madness, which is worthy of attention. He says, " I have constantly observed that in the bourse of the first month from the commencement :.)f the disease a very marked remission takes place. About that period the maniacal excitement, which ^lad previously run its course as an acute disorder, seems to have reached its termination as such, and it is then that it passes into a chronic state, the Crisis having been incomplete. This remission, Which I have watched with the greatest accuracy, must be attributed to the complaints which are complicated with madness at its commencement." The author implies, though he does not clearly express himself, that the natural termination of the '■disease, when unimpeded by complication with 'other maladies, or by more or less of organic le- sion in the brain, is in the very early stage. [It is exceedingly important to bear in mind the immense difference in the curability of insanity i-in recent and in chronic cases, which has been -'observed in other institutions besides those cited. In two " Appeals to the People of Pennsylvania on the sulrject of a Slate Asylum for the Insane " Poor," which the writer prepared as Chairman of a Committee, the results in various insane establish- ments of this country were brought together. In one, the ratio of recoveries of those in whom the insanity was of less than 12 months' duration, was stated to be 82$ per cent.; whilst of the old cases it was only 15£ per cent. At the York West Riding Asylum, of 318 cases that had existed, according to Sir William Ellis, (.4 Treatise on the Nature, Symptoms, Causes, and Treatment of Insanity, Lond. 1838,) from one to thirty years, only 26 were cured ; and of 173 old cases in the Bloomingdale Asylum, New York, in 1835, only 16 were restored. Few patients who are more than 60 years old when attacked—it would seem from the experience of M. Esquirol—recover ; and the result of the greater part of inquiries would appear to show, that restoration is most frequent in youth, and less so as age increases. Dr. Woodward, however, affirms, that in the Massachusetts State Hospital, mercial affairs, or to fulfil the duties belonging to their appointments. Such cases may be about one-tenth in the number of recoveries. Convalescents are as subject to relapse as those who are advancing towards recovery from other diseases. But lunatics are in many instances like- wise prone to a recurrence of the disease after it has been entirely removed, or at least after its ma- nifestations have long ceased to be observed. The same observation may be applied to other disorders of the nervous system. It would seem that one attack of disease has in these cases left the patient with a stronger predisposition than he formerly had to the complaint, whatever it may have been, and that the morbid tendency is strengthened after every renewed incursion. The most trifling cir- cumstances have in these instances sufficient in- fluence to produce the morbid condition of the brain and of the mind. At length the patient is scarcely ever in a lucid state ; the intervals lessen in duration, and become more and more imperfect in degree, until disease finally becomes in a great measure permanent. The proportion of cases in which madness is recurrent has been overrated. According to M. Pinel, in 71 cases out of 444 recoveries, relapse took place, or, rather, the disease was in those in- stances recurrent. This gives somewhat less than one-sixth of the whole number as recurrent; but the same writer allowed that out of the 71 cases 20 patients had previously relapsed, or had under- gone several attacks, 16 had left the hospital at too early a period, 10 came afterwards under treatment and recovered without relapse, 14 had given them- selves up to grief and intemperance, and several others were under circumstances unfavourable to continuance in health. M. Esquirol published a report of 2804 recoveries, in which number only 292 recoveries of disease took place, that is, a little more than one-tenth. M. Desportes, however, has stated that, in 1821, 52 recurrent cases were re- cognised at the Bicetre, out of 311 admissions, that is, about 17 in a hundred ; at the Salpetriere in 454 admissions there were 66 relapses, about 15 in a hundred, or one-seventh. But in the pro- at Worcester, persons attacked with insanity after ■ portion of recurrent cases indicated by this last forty years of age, recover in much greater pro- portion than those attacked before that age.] Recoveries from madness are in many instances complete. There are numerous persons who have been insane for six or twelve months, or during a longer period, and have afterwards entirely recov- ered the vigour of their intellectual faculties, so as to be capable of as great and effective mental ex- report, it is probable that there were, as M. Georget has well observed, many cases which had been discharged in a state of incomplete recovery, as well as a considerable number of drunkards, who come habitually every year to spend a few weeks in the Bicetre or the Salpetriere, having been picked up in the streets in a state of intoxication. In all instances we may consider it as certain that ertions as previously to the attack. Others, and I the improbability of recurrence increases with the perhaps these are the majority, are curable only to i length of the interval of time during which the a certain point. These persons remain, as M. I patient has existed without manifesting signs of Esquirol has observed, in such a state of suscepti- , renewed disease, and that it is also greater in pro- bility that the slightest causes give rise to relapses, portion to the completeness of the recovery. When and they only preserve their sanity by continuing j the energy of mind is fully restored, relapse is to live in a house where no mental agitation or \ much less to be feared than when it remains weak inquietude, no unfortunate contingency is likely to fall to their lot, and throw them back into their former state. There are other individuals whose faculties have sustained such a shock that they are never capable of returning to the sphere which they had held in society. They are perfectly ra- tional, but have not sufficient mental capacity to become again military officers, to conduct com- and excitable. Second Termination —Fatuity—Dementia— Amentia.— The ultimate tendency of madness when protracted, and the state to which insane persons, if they do not recover, are in general sooner or later reduced, is that of fatuity. The fatuity which constitutes the last stage of mental derangement differs in its phenomena from oon- 44 INSANITY, of twenty, or five-an* genital idiotism. It has more resemblance to the i a paroxysm of a cute ™a™ °'* nJ ., Such r* imbecility of extreme old age, but from this last twenty, or thirty days cont.nu ac & ^J* affection, which we shall describe at the conclusion ' r of the present treatise, it is distinguishable and in many instances very different. For the sake of greater precision we shall divide maniacal fatuity into two grades or stages. The first is that state which Esquirol and Georget have named demence or dementia, a term which is established by the authority of these writers, and has been received into general use; the second stage of fatuity, which is the last period of mental decay, and presents an almost entire obliteration of the faculties, may be properly distinguished by the term amentia. 1. Dementia___The approach of dementation, or the first period of fatuity, is indicated by a comparative state of calmness succeeding to the previous excitement of the maniacal period. It is not the calmness of returning reason, but the result of mental activity worn out, the subsidence or obliteration of the affections or moral feelings, and the decay even of physical sensibility. It has been well remarked by M. Georget that the cha- racteristic of dementation is a forgetfulness of the past, with a total indifference as to the present and future. Demented persons are generally quiet and inactive; they take little notice of persons or ex- ternal things, without appearing to be occupied by any internal emotion or train of thought. They often, however, smile or laugh without any appa- rent reason, or sing, or pronounce, as if accident- ally, single words or sentences. Some remain for days or weeks without uttering a word, or betray- ing by look or gesture the least consciousness of external impressions. Such impressions, however, are sometimes afterwards discovered to have been not entirely unobserved. Many appear, by their looks or replies to questions, to know and remem- ber their friends or relatives, but scarcely display signs of emotion or sensibility on being visited by them. Not a few even in this state are capable of being employed in mechanical occupations. Females knit or sew, or perform any work with their hands to which they have been previously habituated; and men draw, or write letters or sentences, in which, however, their imbecility is generally conspicuous. Some patients have occa- sional periods of greater excitement, in which the symptoms of a more active state of madness re- sume their prevalence. In other instances mere physical activity displays itself at intervals in pe- culiar ways, as by running, jumping, or walking round continually in a circle or determinate figure. The physical health of patients thus affected is in general tolerably good ; they are often fat, have good appetites, digest their food, sleep well, and if in the previous stages of the disease they had been emaciated, they often recover their natural degree of plumpness on the approach of dementia. Hence of the system, are in many instances succeeded!, perfect Nationality." The same result has bee, observed on the restoration of demented perso* or of maniacs in the advanced stage of insan^ after severe attacks of fever of that kind which. usually attended with delirium. Such attacks an often fatal to lunatics; but of those who recowi them not a few are subsequently restored to tin possession of their faculties. These instances of restoration from fatuity take place only after the first stage. When the disease has passed into complete amentia, it is al- together hopeless. 2. Amentia.—Scarcely any exhibition of human suffering can be more deeply affecting than the aspect of a group of lunatics reduced to the last stage of fatuity, and those who have never wit- nessed such a spectacle can hardly imagine so ab- ject a state of mental degradation. In a group of this description an individual may be seen always standing erect and immovable, with his head and neck bent almost at right angles to hit trunk, his eyes fixed upon the ground, never turn- ing them round, or appearing by any movement or gesture to be conscious of external impressions or even of his own existence. Another sits on a rocking-chair, which she agitates to and fro, and throws her limbs into the most uncouth positions, at the same time chanting or yelling a dissonant song, only capable of expressing a total inanity of ideas and feelings. Many sit constantly still, with their chins resting on their breasts, their eyes and mouth half open, unconscious of hunger or thirst, and almost destitute of the feelings which belong to merely physical life; they would never lie down or rise were they not placed in bed and again raised by their attendants. A great proportion of the patients who are reduced to this degree of fa- tuity are found to have lost the use of their limbs in a greater or less degree by partial or general paralysis. From such a state it is scarcely imaginable that recovery ever took place, but patients in the last stage of fatuity often linger for many years. Their state, however, is not always uniform: some of them have comparatively lucid intervals, at which nature seems to make an effort to light up the mind and recall lost impressions and ideas. A patient has often been observed by the writer of this article, who sits all day in a wooden elbowed chair, with his chin hanging over his breast, ap- pearing hardly conscious of existence and unable to assist himself in the calls of nature, who would not eat if food were not actually put into his mouth. He has been for several years in the same state, except that he occasionally appears to rouse the return of physical health without a correspond- himself, and for a short time to recover an unusual ing improvement in the state of the mental facul- ties, is, as it has been remarked by the writer last cited, an unfavourable prognostic in cases of ma- niacal disease. There are, however, some rare cases of recovery from this first stage of fatuity. Pinel informs us that many, especially young persons, who had re- mained in the Bicetre several years or months in a state of absolute idiotism, have been attacked by degree of animation. At such periods he will sometimes read a chapter in the Bible with a clear voice and a distinct and intelligible articulation. 3. Of the termination of madness in Death___ Madness is not to be reckoned among the diseases which are very dangerous to life. The slate of the brain on which it depends, though incompati- ble with the continuance in a sound state of thosi functions on which the mental operations are a> INSANITY. 45 ^ociated, is yet such as to carry on other processes, 'dependent on the brain, which are subservient to ^physical existence. This conclusion is established in a most con- 'vincing manner by the duration of insanity, and the cases even of longevity which occur among ^lunatics. We are informed by M. Desportes that -among the lunatics at the Bicetre in the beginning ^of the year 1822, one had been lodged there fifty- six years, 3 upwards of forty years, 21 more than thirty years, 50 upwards of twenty years, 157 more than ten years. At the Salpetriere the -entry of patients dated, 7 cases from fifty to fifty- seven years, 11 from fifty to sixty, 17 from forty Uo fifty. The morbid state of the brain is, however, liable to increase beyond the limit above adverted to, and , then the usual phenomena dependent on severe : cerebral disease are manifested. It is well known • that lunatics are subject in a much greater propor- tion than other persons to apoplexy, palsy, epilep- : sy, and all the trains of symptoms depending on different degrees or modifications of cerebral con- . gestion. Another mode by which madness brings on a fatal termination is by the exhaustion arising from - continued excitement. There are many cases of . maniacal disease in which the ceaseless excitement of the feelings, the constant hurry of mind and agitation of body, the total want of rest and sleep, and the febrile disturbance of the system which L frequently ushers in the attack of madness, and is always a prominent feature in cases of this de- scription, bring on a very marked reduction of strength as well as of flesh: the degree of emaci- ation is sometimes extreme. Generally this state of excitement gradually abates, or the means adopted to lessen it and tranquillize the system are attended with success ; but this is not uniformly the case, and some maniacs die completely worn out and exhausted. It is in part owing to this cause that the mortality among lunatics is more considerable during the two first years from the period of their attack than in the succeeding years, a fact which appears to be established by the cal- culations of M. Esquirol. In the Salpetriere the number of deaths is even much greater in the first year than in the second. Of 790 lunatics who died in that hospital between the years 1804 and 1814, it appears that 382 died in the first year from their admission, 227 in the second year, and 181 during the seven succeeding years. Many lunatics are carried off by diseases of the abdominal and thoracic viscera, which are compli- cated with madness. Pathology does not enable us to explain the connection between organic dis- eases of the lungs or bowels and disordered action of the cncephalon, and hence many have been inclined to regard the combinations of morbid states to which we now advert as accidental. They are perhaps too numerous to be attributed to chance. The combination of madness, as well as of some other diseases of the brain and nervous system, with diseased states of the liver and of the intestinal canal, was pointed out some years since by the writer of this article. The conjunction of insanity with pulmonary phthisis is a fact estab- lished beyond doubt by the observations of M. Esquirol, who remarks that phthisis often pre- cedes the appearance of melancholia, or accompa- nies it. The disease of the lungs is in these in- stances latent; the patients lose their strength, become emaciated and suffer under slow fever, sometimes attended with'cough and diarrhoea; the phenomena of madness rather increase than abate under these circumstances, and continue until death. On the examination of the body, the lungs are found tuberculated or affected by melanosis. Diseases of the heart are not unfrequently com- plicated with madness. We are assured by M. Foville, that of the bodies of lunatics which he examined after death during three years, five out of six displayed some organic disease either of the heart or the great vessels. This was very fre- quently hypertrophy of the heart. These morbid changes, however, are probably, as M. Foville has observed, more frequently results of the continued agitation, the violent efforts and cries, which in such patients bring on diseases in the thoracic organs, than predisposing causes of cerebral dis- ordei Diseases of the intestinal canal, whether they exist or not at the onset of the maniacal attack, are subsequently among the frequent causes of death. A state of obstinate constipation often continues for a long time, attended by its usual accompaniments. It gives way, and is followed by or alternates with diarrhoea, which wastes the strength of the patient and terminates in a fatal dysentery. When the body is examined, the in- testines are found sometimes distended and loaded with indurated matter, at others empty and pale, with disease of the mucous coat, discoloured and abraded patches or ulceration, and gangrenous spots. In protracted cases death either results from in- crease in the disease of the brain, which up to a certain degree had only subverted the operations of that organ subservient to the mental function, and at length becomes incompatible with the merely physical functions of the same viscus; or it is the result of accidental disorders, which, owing to the peculiar state of the brain and other organs in lunatics, are more than usually fatal. Fatuity or inveterate lunacy becomes compli- cated with paralysis. M. Esquirol says that of the number of persons who die in a state of lu- nacy, one half are paralytics. This paralysis of the demented is a peculiar affection, for we are not now referring to hemiplegia, attacks of which are liable to occur at all periods of madness, either ushered in by apoplexy or without it, and which frequently carry off maniacal patients. The general paralysis to which lunatics in the advanced stage are most subject shows itself first in the mus- cles of articulation ; patients have some difficulty and imperfection in speech, which is in the be- ginning so trifling as to escape those whose atten- tion is not particular'y directed to the circum- stance. The muscles of the limbs and trunk become subsequently affected; the patient walks with a tottering or shuffling gait, and his trunk is bent forward ; his hands shake; his limbs become emaciated and feeble; sometimes he bends towards one side, and at length passes his time in a sitting posture, and bent forward, or takes to his bed, when the sphincters gradually lose their power, 40 INSANITY. sloughs take place about the back, the sacrum, and elbows, followed by gangrene and death. Many lunatics in the advanced stage labour under a degree of cachexia bordering on scurvy. The skin is beset with scaly or papular eruptions, or discoloured in patches; furunculi appear in different parts of the body, which are much dis- posed to become sloughy; the gums become red and sore, and bleed ; the surface of the body is cold with a clammy perspiration ; diarrhoea, and abdominal pains accompany these symptoms; the patient apparently suffers under defective nutrition and a gradual decay of physical life, and dies in a state of extreme emaciation or marasmus. The preceding are perhaps the natural sequels of the diseases under which lunatics suffer in con- nexion with their original complaint. A great number, however, are carried off by disorders which may be considered as accidental, but to which the condition of body in patients of this description renders them more than other individ- uals liable. Fevers which assume more or less of the typhoid character, severe catarrhs, and pulmo- nary affections, are the most frequent of them. It will be supposed that fevers which affect the brain are fatal to lunatics, and such is the fact in a very marked degree. The diagnosis of accidental diseases in lunatics presents, as M. Georget has well observed, re- markable difficulties. Some patients of this de- scription are continually making unfounded com- plaints, deceived by their erroneous or fancied sen- sations. On the other hand, many lunatics labour under very severe affections without revealing them by an expression, either because these affec- tions are latent and do not occasion suffering, or because the disturbed state of their minds does not allow their sensations to reach the centre of perception. In this last relation the medical treat- ment of lunatics is much m«re obscure and diffi- cult than that of young children, because the lat- ter are conscious of their ailments, and express them by their cries. « When we observe a luna- tic, who had previously been agitated and furious, becomn morose and taciturn, and at the same time lose his appetite, seek repose, and display a suffer- ing and dejected expression, we ought to examine him carefully: he is threatened with some acute disease. The development of symptoms will soon point out the seat and nature of the complaint, and consequently by what sort of means it is to be opposed. But chronic affections are so slow in their approach and concealed in respect to their symptoms, that they often reach to a very ad- vanced stage before their existence is suspected, unless the organs affected are examined before their diseased condition has manifested itself. We find the lungs full of tubercles, with cavernous excavations and abscesses, or in a state of atrophy, in the bodies of individuals who had neither coughed nor expectorated, nor experienced pain or dyspnoea during life ; they had become gradu- ally debilitated, had taken to their beds, and after a continually increasing emaciation, had at length sunk. The disorganization of the lungs had only been discovered by the aid of auscultation and percussion. We must not then wait for the ex- pression of complaints on the part of lunatics in order to have our watchfulness excited to the means which are necessary for preserving the. existence." »„«.„».««„ Sect. IV. —Of the Cause* of Insanity.. Prerlispo*in? Causes. 1. Natural Conslitution.-A^e the circa* stances in the previous condition of an individual which prepare him for sustaining the attack of tbj, disease, the most important is a certa.n pecul.anl, of natural constitution. This consists chiefly,,, it is probable, in a particular organization of thi brain and nervous system, rendering those individ. uals so constituted liable to become insane whei exposed to the influence of certain agencies, which in other persons either give rise to a difib ent train of morbid phenomena, or^ are, perhaps, devoid of any injurious effects. The constihj. tional peculiarity which predisposes to madness ii not distinguished by any remarkable externsl characters. That such a natural tendency, how- ever, actually exists, and in all instances is a ne- cessary condition to the development of maniacal disease, is to be inferred from the consideration that similar exciting causes exert their influence on other persons without producing a like effect. Among the agents that give rise to madness, there is none more influential than intemperance, or the frequent use of ardent spirits. A considerable proportion of lunatics in the lower classes of so- ciety owe their disease to this cause. But it is only in a certain proportion of persons addicted to intemperance that the phenomena of madness make their appearance. Others, under the influ- ence of the same noxious cause, aie affected with apoplexy or paralysis ; in many, the brain escapes and the liver becomes disordered, or dropsy takes place, with or without disease of the liver; in some, the lungs become the seat of morbid changes. It is evident that there must be an ori- ginal difference in the habit of body whence arises the diversity of results brought about by the same or very similar external agencies. This original difference is apparently a peculiarity in the con- genital constitution of each individual. It maj be transmitted from parents, or it may arise dt novo, as other varieties in the congenital structure are known to do. Hence it is comparatively of little moment, as far as an individual is concerned, to inquire whether his morbid predisposition has been derived by hereditary descent, or has sprung up with himself. It may, indeed, be observed that peculiarities which arise in a race are often com- mon to several individuals even in the. first gener- ation. Albinos, for instance, though the offspring of parents of ordinary complexions, very frequently have brothers or sisters resembling themselves. In like manner, diseases which appear for the first time in a family often affect several members of it, who partake of the same peculiarity of tempera- ment or congenital structure. If these remarks are w,H founded, it must be apparent that hereditary madness is not less cura- ble than a disease having symptoms of the same description, which has not been previously observ- ed in the family of the person affected by it. That the predisposition to madness, when it has once arisen, is frequently transmitted, is a fact too well established to admit of doubt, it constitutes a feature in the history of the disease. The hereditary transmission of this'tendency if INSANITY. 47 remarked by M. Esquirol to be more general among the opulent than the lower classes. He states the proportion of hereditary cases among the former to be one-half, among the latter to be one-sixth. This, however, seems to be a mistake, as it appears by his table that of 351 cases at the Salpetriere, 105, or nearly one-third, had the disease by inheritance. Among 264 patients of a superior class 150 cases were, according to the same writer, hereditary. He accounts for this difference by referring to the exclusive marriages of aristocratical families, a cause which had for- merly in France much influence. It remains to ' be determined whether the same difference is to be observed elsewhere under circumstances not admitting this explanation. The same writer affirms that persons born be- fore their parents had become maniacal are less subject to mental disease than those who are born after the malady had displayed itself. He makes a similar remark as to those who inherit the dis- ease only on one side, in comparison with persons whose paternal and maternal ancestors had been affected by it. According to Burton the offspring " of parents advanced in years are more subject I than others to melancholy madness. Another observation relating to the hereditary transmission of this morbid tendency is, that the disease is apt to show itself in different individuals of a family at a particular period of life, and in all • of them under a similar character. M. Esquirol : has made this remark, and he has mentioned several facts in illustration of it. " Two sons of " a merchant of Switzerland died insane at the age of nineteen years. A lady, aged twenty-five years, was attacked by puerperal madness; her daughter suffered in like manner at the same age. In one family the father, the son, and the grand- son, all committed suicide about their fiftieth year. There was at the Salpetriere a prostitute who ■ had thrown herself into the river seven times; her sister drowned herself in a fit of intoxication. There exists near Nantes a family in which seven brothers and sisters are in a state of dementia. A gentleman, affected by the first events of the Revolution, remained during ten years shut up in his chamber. His daughter, about the same age, fell into a similar state, and refused to quit her apartment. This predisposition, which manifests itself by external signs, by peculiarities in the moral and intellectual character of individuals, is not more surprising in connection with madness than are the instances of gout, of phthisis pulmo- nalis, and other diseases, in a different point of view. It may be traced from the age of infancy : it furnishes the explanation of a multitude of ca- prices, irregularities, and anomalies, which at a very early period ought to put parents on their guard against the approach of insanity. It may furnish useful admonitions to those who preside over the education of children. It is advisable in such cases to give them an education tending to render the habit robust, and to harden it against the ordinary causes of madness, and particularly to place them under different circumstances from those with which their parents were environed, j It is thus that we ought to put in practice the [ aphorism of Hippocrates, who advises to alter the j constitution of individuals in order to prevent the | diseases with which they arc threatened by the hereditary predisposition of their family." M. Esquirol affirms that many facts have oc- curred within the sphere of his information prov- ing a strong predisposition to madness to have arisen from some accidental fright sustained by the mother during pregnancy. Marked cases of this description are said to have occurred during the period of the Revolution. 2. Age.—Persons in the middle period of life are most subject to attacks of insanity properly so termed. M. Esquirol has remarked that imbecility is the predominant mental disorder of childhood, mania of youth, melancholia of more advanced manhood, and dementia of old age. The years during which madness most fre- quently makes its first appearance are those be- tween thirty and forty in the age of the individual; next to these are the years between twenty and thirty; thirdly, are those between forty and fifty. Insanity is comparatively rare in the earlier as well as in the later periods. The case, however, of a child who had been maniacal from the age of two years was noted by Joseph Frank at St. Luke's in 1802. M. Esquirol mentions besides three instances of maniacal children. Dr. Haslam and others have reported some cases of the same description, but they are not of frequent occur- rence. M. Georget has observed that out of the num- ber of 4409 lunatics in different hospitals in France and England, 356 were between the ages of ten and twenty, 106 from twenty to thirty, 1416 from thirty to forty, 861 from forty to fifty, 461 from fifty to sixty, 174 from sixty to seventy and only 35 upwards of 70. The following table, given by Dr. Burrows from Reports of the French hospitals, tends fur- ther to illustrate the proportional frequency of madness at different periods of life, and it has the advantage of distinguishing the sexes. Ages. Men. Women. Total. From 10 to 19 — 78 .. ... 62 .. ... 140 20 to 29 — 198 ... 267 .. ... 465 30 to 39 — 248 ... 324 .. ... 572 40 to 49 — 231 ... 290 ... 521 50 to 59 — 132 ... 218 .. ... 350 60 to 69 — 119 .. ... 146 ... 265 70 to 79 — 76 . . ... 101 .. ... 177 80 to 89 — 7 . . 4 .. ... 11 Ages ? 6 unknown. > ... 0 .. 6 1,095 1,412 2,507 Under 50 years ~) -,,-,. of age. 5 .. 943 .. .. 1,698 Above 50 years 7 „._ .. 469 .. .. 890 of age. 2,507 3. Sex.—If we may believe Caelius Aurelianus, madness was among the ancients more frequent in males than in females. In France, according to M. Esquirol, the reverse of this statement is true. This writer attributes the greater compara- tive liability of modern females to the vicious sys- tem of modern education, to the preference given 49 INSANITY. to mere accomplishments, to the reading of ro- mances, which gives to young persons a preco- cious sensibility, premature desires, and ideas of perfection which they nowhere find realized, to the frequenting of plays and assemblies, the abuse of music, and want of occupation. In England, he observes, where women have an education more strengthening to the mind, and where they lead a more domestic life, the proportion of female lunatics to the male is less considerable. These considerations may account for the facts in respect to the higher orders; but as the observation in- cludes those who are the inmates of hospitals, we must have recourse, in order to explain it, to the physical circumstances in which the condition of females differs from that of the male sex. The difference is in fact so great in France, that M. Pinel, in 1802, calculated that there were two female to one male lunatic. According to the report " Sur le service des alienes," by M. Des- portes, made at Paris in 1823, it appeared that from 1801 to 1821 the number of males admitted at the Bicetre was 4552, and that of females at the Salpetriere during the same period, 7223. At Bethlem, according to Dr. Haslam, 8874 lunatics were admitted in the course of forty-six years, of whom 4832 were females, 4042 males. At St. Luke's, according to a statement made to a com- mittee of the House of Commons in 1807, the number of females is usually greater than that of males by about one-third. In comparing a num- ber of statements from different countries, M. Es- quirol, however, concludes that the excess in the proportion of female lunatics is not so considerable as it is generally supposed to be, and that it does not, in fact, greatly exceed the difference which exists between the sexes in the ordinary state of the population. It is greater in some countries than in others, and in France than in England. [Taking the result of inquiries in various parts of the civilized world, it would not seem that there is much difference between the sexes. Of 76,526 cases, enumerated with this view, 37,825 were males, and 38,701 females,—the ratio of males to females being thus as 37 to 38 nearly.] 4. Celibacy. — M. Georget was inclined to reckon celibacy among the predisposing causes of madness, from considering the following facts de- tailed in the report of M. Desportes. Out of 1726 female lunatics 980 were single women, 291 were widows, 397 were married per- sons. Out of 764 males 492 were single, 59 were widowers, and 201 were married. These relative numbers appear remarkable, but in estimating the result we must take into our account the fact that married persons lead in general more regular lives than the unmarried, that they are generally more fixed in their pur- suits and their condition as to maintenance and employment, and less subject to causes which agitate the mind and excite strong emotions. These remarks apply, however, principally to men, and the difference is equally great among females. 5. Temperament.—A constitution of body pre- disposing to violent passions also predisposes to madness. With respect to complexion, which is generally supposed to denote varieties of temperament, ft does not appear that there is any particular shadj or hue of eyes or hair which marks a predisposi. tion to this disease. On a comparison of facu collected from several countries, M. Esquirol has not been able to discover any decided difference. In the Parisian hospitals a chestnut colour of both eyes and hair prevails, which is the general colom among the people of the north of France. 6. Season.— M. Georget has given briefly the result of reports indicating the influence of sea- sons. It seems that during the six summer months a greater number of persons are received into the lunatic asylums than in the six months of winter. [According to Dr. Woodward, (Eleventh Report of the State Lunatic Asylum at Worcester^ Mass., p. 41, Dec. 1844,) there were in winter the least number of admissions, the fewest discharges, and the fewest deaths. M. Andral (Cours de Pathologie Interne) esti- mates the average frequency of insanity in the different seasons in the following order—summer, spring, winter, autumn. This applies especially to mania. Monomania and dementia appeared to occur equally at all seasons. In Naples, mono- mania was observed to be more frequent in the month of September. As regards the termination of the disease, Borne have assigned the greatest number to autumn; and the greatest mortality to December, January, and February. 6*. Moon. — Not many years ago, it was uni- versally believed that the full moon exerts a de- cided influence on the insane; hence the names lunatic, moon-struck, &c, applied to these unfor- tunates. It is now, however, settled by the obser- vations of Drs. Haslam, Esquirol, Woodward, and others, that if the light of the moon be excluded, the insane are not more affected at the full of the moon than at any other period. Nor is the com- mon idea of a direct influence of the sun at the summer solstice better founded. The whole effect, in the first case, seems to be induced by the stimulus of light; and in the latter, by that of heat;—the two being conjoined at the summer solstice, in consequence of the length of the days at that period. (See on this subject, the writer's Human Health, p. 184, Philad. 1844, and Dr. Woodward, op. cit., p. 67, Boston, 1844.)] 7. Among the most powerful of the causes which render persons obnoxious to madness, must be^ reckoned previous attacks of the same disease. When such attacks have been repeated, the pre- disposition becomes increased. There are in- stances, however, of persons who, during a cer- tain period of their lives, have been subject to repeated attacks of maniacal disease, but have recovered entirely, and have lived many years in a state of perfect sanity. 8. Other diseases of the brain, such as apo- plexy and paralysis, sometimes predispose to mad- ness, or are followed by it. Epilepsy of a severe and inveterate kind is sometimes complicated with insanity. These cases are distinct from the fatuity which is often the result of long-continud epilepsy. The form of maniacal disease cob- nected with epilepsy is peculiar, and this may be considered as constituting a distinct disease It INSANITY. 40 'has been ably described by the late Dr. Edward Percival. 9. Education.—An erroneous and unsuitable method of education is among the most influential causes of insanity. There are two diffeient points of view under which the injurious effects of wrong 'education may be considered. By too great in- dulgence and a want of moral discipline, the pas- sions acquire greater power, and a character is formed subject to caprice and to violent emotions : a predisposition to insanity is thus laid in the temper and moral affections of the individual. The exciting causes of madness have greater in- fluence on persons of such habit than on those whose feelings are regulated. An overstrained and premature exercise of the intellectual powers is likewise a fault of education which predisposes to insanity, as it does also to other diseases of the brain. These are two considerations which are of the greatest importance with respect to the welfare of families to which an hereditary consti- tution may belong, rendering them more liable than others to cerebral diseases. They are dis- tinct in themselves, and each might furnish a theme for an extensive treatise, most valuable in a practical point of view. Under the first head it would be necessary to consider the efficacy of those plans of education of which the professed object is to form a character remarkable for sedate- ness, for the strict discipline of the feelings, and, as far as this is attainable, for the abolition of strong passions and emotions. Such, undoubt- edly, would be the kind of moral education best adapted for those who are constitutionally liable to insanity. The second remark, on the regula- tion of mental exercise in young persons whose nervous systems are feebly constituted, has a more extensive bearing than on the subject of insanity. It brings forward a suggestion which is of general interest in these times in which mental exertion is stimulated to the utmost, and when, in reality, all the physical and moral powers are sacrificed to the cultivation of intellect, or in many in- stances to the mere acquisition of knowledge. Exciting Causes of Madness.—The immediate causes of madness are in part physical agents, and in part moral. Perhaps it may be remarked that the former are the most prevalent causes of madness in the lower ranks of society, and the latter in the higher class, whose intellects are more developed, and whose minds are subjected to more extensive influences. 1. Among physical causes of madness, one of the most frequent is the immoderate use of intoxi- cating liquors. There is hardly a tribe of the human race who have not succeeded in inventing some method of producing intoxication. Ardent spirits are perhaps, of all, the most injurious in their effects, particularly on the lower classes in the northern countries of Europe and America. It has been repeatedly observed that a large pro- portion of the cases admitted into pauper lunatic asylums arise from this cause. They are in general to be reckoned among the cases most easily cured; for, although this is not uniformly the tact, it often happens that when the exciting cause is removed, the effect begins to lessen, and eventually ceases. When these patients are pre- vented from obtaining stimulating liquors, and are Vol. III. —7 a treated with sedative remedies, they quickly show signs of amelioration and the subsidence of disease. The use of opium and other stimulants is among the exciting causes of madness, though of much less general agency than the ordinary means of intoxication. [Alcoholic liquors are a common cause of one form of delirium—delirium tremens,- but, so far as the writer has observed, not of insanity. In this country, where delirium tremens has pre- vailed to a great extent, and where a good oppor- tunity exists for noticing the effect of alcohol in inducing insanity, the writer's experience has not exhibited to him a great many that could be un- hesitatingly referred to it. The fact, too, of the number of insane among the Society of Friends, who rarely indulge in any form of alcohol pota- tions, is, so far as it goes, against the idea of alcohol being an extensive cause of mental aliena- tion. It is proper to add, however, that in the Reports of most of the insane asylums, intempe- rance is recorded as a common cause.] 2. Blows on the head, and exposure to ardent solar heat, are well known to be occasionally the exciting causes of madness. It is plain that they act by bringing on inflammation, or a state border- ing on inflammation, in the encephalon. The same remark may be made with respect to mer- cury, as used in syphilitic diseases. It is proba- bly an error to suppose that syphilis is itself a cause of madness. 3. Intestinal Irritution.—A disordered state of the intestinal canal often becomes a cause of disturbance in the brain, by whatever antecedents the former disease may have been induced. The state of the intestinal canal, to which we allude, is itself much more frequently of an inflammatory nature than it has generally been imagined, or at least than it was formerly supposed to be. In that condition of the canal which gives rise to costiveness, alternating with diarrhoea, and ac- companied with indigestion, flatulence and eruc- tations, anorexia and nausea, transient but often acute pains in the hypochondria, livid and yellow suffusions of the skin, viscid secretions in the mouth, or redness of the fauces and palate, with a glazed and dry surface, the whole train of symptoms often depends upon a low degree of chronic inflammation in the mucous membrane of the intestinal canal; and this is perhaps a fre- quent, if not an ordinary state in those cases in which disorders of the nervous system supervene on complaints of the stomach and bowels. This form of disease has been described by Dr. Ferriar and several other practical writers ; but it is to M. Broussais that we are indebted for a more ample development of its pathology. The enteric disorder, which lays the foundation for maniacal symptoms, as well as for other affec- tions of the nervous system, is the result in differ- ent instances of various and very diverse noxious causes. The most frequent is excess in the us« of stimulant and indigestible food. Too great in- dulgence of the appetite among the more opulent, and among the lower classes long-continued con- stipation, unwholesome diet, the use of salt provi- sions, exposure to cold and want, or neglect of warm clothing, give rise to diseases of the same description. 50 INSANITY. Intestinal worms are one of the results of con- stipation. Madness produced by the last men- tioned cause is probably of very rare occurrence. M. Esquirol has, however, mentioned a remarkable instance of maniacal disease, affecting a young man, who was cured at two different periods by the expulsion of a large quantity of worms from the intestinal canal. 4. Causes depending on Stales of the Uterine System.—States of the general system connected with irregularity of the uterine functions are well known to coexist with or to display themselves in various affections of the brain. Among them madness is one. Maniacal affections of this class may be mentioi.ed under three heads. a. Dysmenorrhreul Affections.—Some females at the period of the catamenia undergo a consi- derable degree of nervous excitement: morbid dis- positions of mind are displayed by them at these times, a wayward and capricious temper, excita- bility in the feelings, moroseness in disposition, a proneness to quarrel with their dearest relatives, and sometimes a dejection of mind approaching to melancholia. These are distinct from the cases of hysterical affection connected with the same periodical causes of excitement. The former are sometimes the preludes of a far more permanent disease. b. Suppressions of the Catamenia. — Sudden suppressions of the catamenia are frequently fol- lowed by diseases of the nervous system of vari- ous kinds. Females exposed to cold, undergoing powerful excitements, sustain a suppression of the catamenia, followed in some instances immedi- ately by fits of epilepsy or hysteria, the attacks of which are so sudden as to illustrate the connec- tion of cause and effect. In attacks of madness the catamenia are for the most part wholly or par- tially suppressed during the early periods, and in many cases it is not easy to say whether the sup- pression is the effect or the cause of the disease. There are instances, however, in which the cir- cumstances sufficiently indicate the order of con- nection. Dr. Burrows has detailed a case in which suppression brought on by manifest causes was followed by mania. We have already alluded to the case of a young female mentioned hy M. Esquirol, who suddenly exclaimed that she was cured of her disorder; her catamenia had flowed spontaneously, and her restoration to sanity was the immediate consequence. Facts so decisive in their bearings on pathology are not of very fre- quent occurrence, but their evidence reaches far- ther than the individual cases recorded. It often happens that after some weeks or months in the duration of madness, the catamenia, though previously deficient, become restored nearly to their usual state. This, like the other indications of improvement in merely physical health, is only a favourable sign when it is accompanied by some amendment in the state of the mental faculties. Without any such change, it rather gives reason to apprehend that the disorder is becoming inve- terate, and perhaps already making its transition from mania into an incipient stage of fatuity. c. Puerperal madness is another modification of the disease connected with the state of the uterine functions. As this form of insanity is a most im- portant subject, and in circumstances very pecu- liar, we shall allot a distinct section towards thj conclusion of this treatise to the consideration of its history and pathology. 4*. [Excessive venery has been regarded by many as a cause of insanity, and especially J dementia. In the annual reports of several of«f| insane institutions and penitentiaries, many catej are referred to masturbation; yet its influence would certainly seem to be exaggerated by soon observers. It is a common vice everywhere, and is very likely to be practised to a greater extenl in such institutions ; but it cannot be considered as by any means proved, that masturbation wsi the cause of the insanity in many of the reported cases. Often, doubtless, it is the effect. A table of the causes assigned for insanity in dif- ferent insane institutions of Great Britain and this country is given by Dr. Woodward, in the Ele- venth Report of the State Lunatic Hospital at Worcester, Mass., Boston, 1844.] 5. Metastasis.—The pathological fact, that dis- eases of the brain, and among others that froa which madness results, supervene on the cessa- tion of various discharges, on the healing of old ulcers, on the disappearance of cutaneous erup» tions, on the cessation of inflammatory disease in membranous and other structures, on the removal of tumours, has been observed with greater or less attention by practical writers on medicine from tin time of Hippocrates. Many cases illustrative of this fact are to be found in the works of Hildanus, Tulpius, and Hoffmann ; and Sauvages, among thi forms of madness, has reckoned one which hi terms metastatic. M. Esquirol says that even a cessation of the usual discharge from the nostrils, of leucorrhcea, of blennorrhagia, as well as the disappearance of scabies, of herpes, of gout and rheumatism, has produced madness. In general it may be observed that the suppression of acuta eruptions, whether pustular, exanthematic, or ery- sipelatous, is followed by acute inflammatory affec- tions of the internal organs; in such cases the brain or its membranes are attacked by phrenitis or meningitis; while the disappearance of chronic disorder of the same class is the precursor of mental aberration. The suppression of more copi- ous discharges, the removal of large tumours, the disappearance in dropsical cases by rapid absorp- tion of deposited fluids without increased excre- tion, has been followed by determinations of blood to the head, giving rise to fatal apoplexy or severe convulsions. 6. Moral Causes of Insanity. — Among the moral causes of insanity we must reckon all the circumstances which are calculated to give rise to strong emotions, or to excite the passions. Strong emotions, by their operation on the nervous sys- tem, produce injurious effects on the brain, and give rise to disturbed actions in that organ, whence arises mental derangement. The passions and emotions are indeed the principal and most fre- quently productive causes of madness. In barbarous nations, among whom the mind is uncultivated, the passions are proportionally im- petuous, but their sphere is limited, and the intel- lectual and moral faculties are very imperfectly developed. Madness is comparatively rare among such nations. According to Von Humboldt there are very few lunatics among the native Ameri- INSANITY. 51 ans, and a similar observation has been made vith respect to other uncivilized tribes. In Rus- sia, Turkey, and China, madness is unfrequent. n the hospital of Grand Cairo, a city containing 500,000 people, M. Desgenettes found only four- een lunatics. It must, however, not be forgotten , hat in such places many deranged persons are Jmffered to wander about through neglect and the ■ibsence of regulations for police, and that their lumbers thus escape observation ; yet this circum- stance is not sufficient to account for the entire lifference between barbarous and civilized coun- tries, in respect to the apparent frequency and tarity of madness. It might be affirmed that mental derangement is the result of a deviation from the state of nature, if we were to agree with those who look upon barbarism as the natural condition of our species, and represent all that is ennobling and exalted, all that is good and really desirable in human life, as foreign or accidental, and the produce of forced and unnatural culture. In this as in other instances, it has pleased Provi- dence to mix up with the greatest blessings some portions of evil, some ingredients of intense suf- fering: "Medio de fonte leporum, Surgit amari t>aliquid, quod in ipsis floribus angat." • [It has been maintained, that the number of the insane is in a direct ratio with civilization ; but the medical statistics of countries do not exactly 1 establish this ; although there can be no question, that civilized man is more subject to insanity than the savage. From estimates made by M. Briere de Boismont, it would appear, that in England the proportion of the insane to the whole popula- tion is 1 in 783 ; in Wales, 1 in 911 ; in Scot- land, 1 in 573 ; in the Rhenish provinces, 1 in 1000; in Norway, 1 in 551 ; in France, 1 in 1000; and in Italy, 1 in 3785; yet it would scarcely be admitted, that the people of Norway are more civilized than those of France. The proportion of insane in the larger cities has been enumerated as follows : London, 1 in 200 ; Paris, 1 in 222; Milan, 1 in 242; Florence, 1 in 238; Turin, 1 in 344; Dresden, 1 in 466; Rome, 1 in 481 ; Naples, 1 in 791 ; St. Petersburg, 1 in 3133 ; Madrid, 1 in 3350; and Grand Cairo, 1 in 30,714. There is certainly a singular difference between these countries, as there would appear to be between the different states of this Union in the number of the insane; and the difference is by no means easy of explanation. In New Hampshire, when the population did not exceed 280,000, the number of lunatics was estimated at 600 ; in Con- necticut, in a population of 298,000, at 700; in Massachusetts, with a population of about 612,000, there were 1000; and in Virginia, taking the po- pulation at 1,200,000, it is estimated that there were, in 1838, not fewer than from 600 to 800 insane persons. In New York, the ratio in 1835 was considered to be 1 in 887 and a fraction ; and the probability is, that it is quite as great in Penn- sylvania, where, under the lowest estimate, there were probably in 1841 not fewer than 2000 per- sons, lunatic and idiotic, of whom, it has been estimated, that about 1200 may be idiots. The census of the United States has not been taken with sufficient accuracy to enable us to deduce any satisfactory results.] Various kinds of mental excitement have dif- ferent degrees of influence in producing madness, under different social and political circumstances. Among the patients of the Salpetriere, in 323 cases admitted during the years 1811, 1812, M. Esquirol reckoned 105 originating in domestic chagrins, 77 occasioned by poverty and reverses of fortune, 45 by disappointments in love, 38 by fright, 8 by fanaticism. Cases of what is termed religious madness are supposed to be much more frequent than this small proportion seems to im- ply, but it is much to be desired that we could determine the meaning of the expression religious madness, and to what examples of disease it may be correctly applied. There can be no doubt that madness has often been produced by a vehement and impassioned style of preaching. " In the kingdom of Naples," says M. Berthollet, " a custom exists of preaching in favour of missions by a particular set of priests. In order to animate the faith of believers, they accompany their orations with particular acts, which are often of such a nature as to produce too powerful an effect on weak minds. They hold their hands over flaming torches, and whip themselves with scourges garnished with iron points. Their sermons are prolonged till the close of day, and the feeble glare of a few flam- beaus heightens the effect of the scene." " One of these sermons gave occasion to the case I am about to describe. The subject was hell: to heighten the colouring of the frightful picture which the preacher had traced, he took a skull in his hand, and having raised a question as to the abode of the soul to which it belonged, he exclaimed, invoking it, < If thou art in heaven, intercede for us ; if thou art in hell, utter curses.' He then cast it from him with violence. The lady, whose case is subsequently described in M. Berthollet's memoir, was instantly affected by a morbid change in the nervous system. Strong emotions excited by vehement preach- ing produce continually in females and very sen- sitive persons, fits of hysteria, and in those who arc predisposed to mania there can be no doubt that similar causes give rise to attacks of madness. Cases, indeed, are of continual occurrence which establish the fact. But the terrors excited by a troubled conscience, which have given birth in the imagination to gor- gons and chimeras, and monsters of darkness, are sufficient of themselves to produce madness in persons predisposed. None can entertain a doubt on this subject who recollect the stories of men persecuted by the Furies, the appalling self-tortures and mutilations, the blood-stained altars and the hideous divinities, the sacrifices of wives and daughters, the gloomy and hopeless fatalism of the pagan world. There is no remedy for these evils, resulting as they do from the moral and physical disorders of human nature, but the mild and consoling influence of Christianity; and if this religion has been made in some instances the instrument of evil rather than of good, we must recollect that the greatest blessings are capa- ble of becoming by perversion the fertile sources of severe calamities. Perhaps some persons may suppose that if it were possible to divest the minds of men of all religious anxieties at once, together with all belief, they would be gainers by the 52 INSANITY. change. But this experiment has been already tried in France, in a great part, during one period of the Revolution, and the following remarks of M. Esquirol display the results, as far as they relate to the increase or lessening of insanity. " The changes," he observes, " which have taken place during the last thirty years in our moral sentiments and habits, have produced more instances of madness in France than all our political calamities. We have exchanged our ancient customs and fixed habits, our old and established sentiments and opinions, for specula- tive theories and dangerous innovations. Religion now only comes forward as a formal usage in the solemn transactions of life; it no longer affords its consolations to the afflicted, or hope to the desponding. Morality founded on religion is no longer the guide of reason in the narrow and difficult path of life. A cold egotism has dried up all the sources of sentiment; there no longer exist domestic affections, respect, attachment, authority, or reciprocal dependencies; every one lives for himself; none are anxious to form those wise and salutary provisions which ought to con- nect the present age with those which are des- tined to follow it." Sect. V. — Necroscopical Investigations of Madness. Recourse has been had to anatomical investiga- tions with a view to illustrate the pathology of madness, and although such researches have not answered fully the expectations with which they were entered upon, they have led to results by no means devoid of interest in their physiological bearing, and capable, though to a limited extent only, of practical application. This department, as well as most others, of pathological anatomy, may be said to begin with Moriragni. That celebrated writer has, however, related the details of but seven or eight dissec- tions referring to cases of insanity. In these he remarked several facts which later observations have confirmed. He found the substance of the cerebral hemispheres more firm, and that of the cerebellum softer than natural. In one instance the white substance of the cerebrum was hard and of a brownish hue, and its blood-vessels, as well as those of the plexus choroides, much dis- tended with blood : in another there was harden- ing of the hemispheres and softening of the fornix, fulness of the cerebral vessels, adhesion of the pia mater: in a third, injection of the meninges and the plexus, hardening of the brain, and softening of the cerebellum. This writer mentions also col- lections of serous fluid in the ventricles and in the tissue of the pia mater. The researches of Greding were much more extensive, and his observations more various. Among the facts remarked by him are thickenings of the cranium, either partially or generally ob- served in 167 ordinary maniacal cases out of 216, in 78 out of 100 cases of raving madness, and in 2-Z out of 30 cases of idiotism or imbecility ; soft- ness of the brain in 51 cases out of 100, espe- cially in mania complicated with epilepsy ; wast- ing of the optic thalami in two eases of dementia; enlargement and contraction of the ventricles ; se- rosity in these cavities, or dryness of their sur- faces ; adherence of the dura mater to the skull; thickened and blue colour of the pia mater; : ness of the tubercula quadrigemina; osseous ct stony concretions in the cerebellum. Dr Haslam has given the details of 37 cases of madness with the appearances discovered on 4» section. In not one of these cases were the brtdj and its membranes free from morbid appearances Tn almost all, the membranes either bore mark of former inflammation or were distended with blood: in 16 cases there was an effusion of serum between the membranes, and in the lateral venui cles this was observed eighteen times. In nine cases the consistence of the brain was firmer than usual ; in seven it was softer, but in 20 not per ceptibly altered. In three cases, the cranium was thicker, and in three thinner than the natural state. In several cases a peculiar looseness of the scalp was observed. The following are the most remarkable of the observations made by M. Esquirol on the morbid appearances of the brain in madness. The cra- nium thick and compact; in other cases thin and porous; often injected with blood : crania irre- gular in respect to the different diameters, and to the cavity of the two sides. Membranes thickened in 11, injected in 19 cases. Basilary arteries ossified in 5 cases. Cerebrum dense in 15, soft in 19 cases. Cerebellum dense in 12, soft in 17 cases. Grey substance abundant in five, disco- loured in 15 cases. White substance injected in 19 cases. Adhesions of the lining membrane of the ventricles in 54 cases. Serous depositions frequent between the pia mater and the arachnoid, as well as in the ventricles. Plexus choroides displaying almost always serous vesicles, (kystes sereuses.) Many other morbid changes have been pointed out by the same writer, such as tumours, vesicles (kystes), partial softenings and ossifica- tions of the arachnoid. Two cases of acute maniacal disease, observed by M. Esquirol, are recorded by M. Georget, (Art. Encephalile, in the Diet, de Medecine,) in which the brain presented all the characteristics of intense inflammation. M. Georget has recorded with great precision the facts which he has himself observed. The fullowing are the most remarkable. Irregular con- formations of the cranium, the prominences of which are developed irregularly, those of the right side being generally larger than those of the left; some skulls having the lateral diameter of eqnal extent with the antero-posterior, and the cavities of the base irregular in extent; some skulls, one in 20, thickened partially or generally ; more fre- quently the bones hard, white, without diploe, resembling ivory ; some very light. Dura mater rarely changed ; sometimes adherent to the skull, thickened, containing deposits of bone. Arach- noid displaying in places additional lamina) of a red or grey colour; sometimes thickened but smooth. Pia mater injected ; or thickened and , infiltrated with serum, giving at first the appear- j ance of a gelatinous deposit. Volume of the brain ; sometimes less than the cavity of the cranium seems to require. Some brains very hard, cut with difficulty ; the white substance glutinous, elastic, and suffering distension; more frequently the brain is soft, the grey matter being pale and yellowish, and the white substance discoloured, , of a dirty white, the colour and consistence of INSANITY. 53 these portions almost confounded. The convolu- tions separated by serosity and the pia mater thickened. Interior cavities of the brain appear- ing in some instances very large, in others small, often filled with a serous fluid remarkably clear and limpid ; plexus choroides exanguious, contain- ing hydatidiform vesicles. Partial softenings of the brain ; erosions, ulcerations of the surface of the ventricles. Cerebellum generally softer than the cerebrum; sometimes partially softened. Meso- cephalon, medulla oblongata, and medulla spinalis rarely display morbid changes of structure. M. Georget has thus summed up in a short compass the morbid changes which have been observed in the heads of maniacal subjects. 1. Bones of the cranium sometimes thickened, some- times without diploe, thick and resembling ivory ; sometimes light and spongy ; inequalities in the form of the cranial cavity. 2. Injections, thicken- ings, serous infiltrations of the pia mater; separa- tions and attenuations of the cerebral convolutions. 3. Surface of the cerebrum softened and adhering to the pia mater, so that the latter, when pulled off, raises portions of the cerebral substance with it ; injected state of the cerebral substance, red- dened colour of the grey portion, marbled violet hues in the white portion, increased consistence of both ; discoloration and general softening of the cerebrum, grey substance yellowish, white sub- stance of a dirty white ; serous collections in the ventricles, particularly in the lateral ventricles ; partial softenings. Other alterations are much less frequent; the annular protuberance, and the four great nervous trunks which take their rise from it, the medulla oblongata and the medulla spinalis, are rarely found to have undergone any material change of structure. Some curious and interesting additions have been made to the morbid anatomy of madness by M. Foville, whose researches were conducted with great accuracy. It was a part of his plan to com- pare, in every instance on the spot, healthy brains with those which were the subjects of examination as having appertained to maniacal patients. By this method some minute peculiarities of structure seem to have been detected which might other- wise have escaped notice. M. Foville's inquiries were carried on at the Salpetriere in conjunction with his colleagues, MM. Delaye and Pinel Grand- champ, when that hospital was under the superin- tendence of M. Esquirol, and subsequently by himself at the establishment of the Lower Seine, an exteusive receptacle for lunatics, which has been for some years under his immediate care. His observations are arranged under the following heads ; 1. morbid changes in the cortical sub- stance ; 2. changes in the white or fibrous sub- stance ; 3. changes in the nerves of sensation ; 4. changes in the membranes ; 5. observations on the skull and the hairy scalp; 6. changes observed in idiots. We shall abstract the most remarkable phenomena noticed under several of these divi- sions. 1. Changes in the grey substance. — In the most acute cases the surface of the cortical portion presents, on the removal of the membranes, a most intense redness, approaching to that of erysipelas. This is still more marked in the substance of the grey matter itself; it is more striking in the frontal x* region than on the temporal lobes, and in the higher regions than in the posterior parts of the brain. In brief terms the morbid changes observed by M. Foville in acute cases of madness are near- ly confined to the following : " Red colour, uni- form and very intense; numerous mottled spots, varying from a bright to a violet red, bloody points, minute extravasations of blood ; diminished con- sistence in the thickness of the cortical substance, coincident mostly with a slight increase of con- sistence in its surface; dilatation of the vessels, resistance of their parietes." In acute cases M. Foville has never observed adhesions of the mem- branes to the cortical substance. Such adhesions are very frequent in chronic cases, and hence, as he conjectures, may be explained the curable na- ture of recent maniacal affections, and the hopeless and incurable state of those patients who have long laboured under madness or dementia. Among the chronic changes of the cortical sub- stance, the most frequent is a very perceptible in- crease of firmness and density in the superficial part, extending to no great depth, but uniform, constituting a distinct lamina, smooth externally, but internally irregular, of a lighter colour than usual, which, when torn off, leaves the remainder of the cortical substance red, soft, and mammillated, somewhat resembling granulations. Something like this external pseudo-membrane of the cortical substance has been noticed in wild animals which have died in a state of confinement, by M. Fo- ville, and is conjectured by him to denote a cere- bral disease in them. The pale and almost bleached hue of the surface of the cortical portion is always connected with this increased density in its sub- stance. Sometimes the surface is rough and granu- lated, containing small grains of a yellowish white. In conjunction with these changes the volume of the convolutions remains natural, or is less than usual. When lessened, there are sometimes linear depressions or irregular pittings on the surface of the convolutions, and in the cortical substance it- self there are small yellowish lacunse filled with a serosity of the same tinge. These lacuna? are sup- posed to correspond with the minute extravasa- tions observed in acute cases. In other instan- ces the diminution of volume is a real atrophy of the convolutions, which appear thin and angular, as if pinched up towards their extremities. This morbid change corresponds with what MM. Gall and Desmoulins have termed atrophy of the con- volutions. It is very frequent in the frontal re- gions of the hemispheres. It often comprises par- ticularly three or four convolutions on each side of the sagittal suture, a chasm filled with serosity occupying the place left by absorption of the cere- bral substance. Co-extensive with this appear- ance is that species of atrophy in the cranium in which the diploe disappears, and the external la- mina approaches the internal, leaving a superficial depression on the head. In these cases of atro- phy of the convolutions, the diminution of sub- stance is confined frequently to the cortical or grey matter. What remains of the cortical sub- stance is harder than natural, and sometimes pre- sents, when carefully examined, a really fibrous structure : it is of darker colour, or seems to sep- arate into layers, of which the exterior is pale and the interior of a rose colour. 54 INSANITY. the state of maniacal induration they are ins* Another state of the cortical substance observed in chronic cases of madness is that of softening (ramollissement) ; this is entirely distinct from the softened state of the external portion already described. The whole thickness of the grey sub- stance is equally altered in these cases; its colour is more brown than usual; its consistence almost liquefied. This extreme and general softness of the corti- cal substance does not necessarily accompany a similar state in the white substance; it is some- times conjoined with a hardened state of the me- dullary portion. In such instances the grey may be sep'aLed from the white matter by pouring j fluids, that an *?^^ *^?£ water upon it. Appearances of this kind seem to PaAmong lunatics affected with general paralysii, M Foville has found these adhesions wanting „ only two cases; and in these two instances the cerebral nerves, the annular protuberance and ths medulla oblongata presented an extreme hardne* The same alteration has been found in the bran, of old men whose voluntary movements have be- come uncertain or vacillating; it has never been seen in lunatics whose muscular powers had re- mained unimpaired. The brains of some lunatics are so full of serou belong to cases of the last degree of dementia with general paralysis and marasmus. M. Fo- ville mentions cases apparently of the same nature, in which limited portions of the grey I substance had disappeared previously to death, j M. Calmeil, in his work on the paralysis connect- ( ed with insanity, has related two instances of a similar description. It seems that the grey substance in other parts of the brain is not subject to a similar change; its morbid alterations coincide with those of the medullary portion. From this remark must be excepted the cortical substance of the cornu am- monis, which is sometimes softened, and at others of a scirrhous hardness. 2. Morbid changes of the white substance.— Morbid alterations of the white or fibrous sub- stance in mad persons are in relation to its colour, its density, and its texture. The white substance is often the seat of vascu- lar injections; sometimes vessels of a certain size being affected, the appearance of bloody points is produced on the section of the white substance. In other instances a finer injection gives rise to a mottled appearance of a deep red or violet colour. A magnifying glass is required in order to discover the vascular injection which produces this appear- ance. These injections of the white fibrous sub. stance do not always coincide with similar injec- tions of the surrounding cortical substance. It is not rare to find in lunatics the fibrous substance of a splendid white; this particular aspect generally corresponds with an increased density of the parts. The hardness of such parts of the brain is sometimes almost fibro-cartilagi- nous. The induration of the medullary substance is, however, not always connected with this re- markable whiteness; sometimes the hardened medullary substance has a yellow tinge or a grey leaden colour. M. Foville attempts to account for this hardening of the fibrous portion of the brain by the supposition that each cerebral fibre has contracted morbid adhesions with the sur- rounding fibres, so as to render their separation impossible. This opinion is offered as more than conjecture with respect to the different planes of medullary substance, of which it is considered as proved that the white substance of the brain con- sists. The fibrous mass of the hemispheres re- sults, according to this writer, from the super- position of several distinct layers or planes, applied one upon the other, and connected by means of a very fine cellular tissue. These planes are easily separable in the healthy state, but in surface of incisions ; sometimes this serous infil- tration is so abundant as to deserve the name of cerebral oedema. A change more rare, which M. Esquirol has remarked, was the presence in the brain of a multitude of small cavities, from the size of a millet-seed to that of a nut, containing i limpid fluid. The section of a brain thus changed is compared to that of a porous cheese. The cavities are supposed to be the sequela? of extrava- sations. The changes in the structure of the cerebellum are analogous in kind to those of the cerebrum, but much more rare. Tubercles and other tumours in the brain are not considered by M. Foville among the causes of madness properly so termed. 3. Morbid changes in the Nerves.—M. Foville is persuaded that he has traced morbid alterations in the nerves corresponding with peculiar phe- nomena of sensation. In a female lunatic, tor- mented by hallucinations of sight, the optic nerves were found hard and semi-transparent through I great part of their thickness. 4. Morbid changes in the Membranes. — In acute cases the only morbid appearance discovered in the meninges is for the most part injection of the pia mater. This injection is generally pro- portioned to the degree of inflammation in the cortical substance of the convolutions. The small arteries and veins, passing from the membrane and penetrating the grey matter, are seen dis- tended with florid or black blood : the arachnoid in the mean time preserves its natural aspect The chronic changes in the membranes consist for the most part in opacity, increased consistence, thickness of the arachnoid, the formation of gran- ulations, and pseudo-membranes on its surface, and the effusion of serosity into the cellular tissue of the pia mater and the ventricles. The arachnoid membrane displays either ex- tensively or in patches a pearly whiteness. The opacity never exists without thickening ; and in those places where the arachnoid and pia mater are naturally contiguous, they are found to be adherent. These opaque patches, as M. Foville supposes, result from the deposition of albuminous layers upon the arachnoid. The observations of the same writer on the pe- culiarities observed in the skulls of lunatics add little to our previous knowledge on this subject-, and his remarks on the conformation and texture of the brain in cases of idiotism do not necessarily belong to the subject with which we are now en- gaged. We shall conclude our abstract of his ob- servations by briefly citing his general inference* INSANITY. 55 "The morbid changes which we have sur- veyed, present many of the anatomical characters of inflammation ; intense, general, diffused, red- ness ; in many cases tumefaction; and lastly, in ''passing to the chronic state, the formation of ad- • hesions between the cortical substance of the con- volutions and the contiguous membrane; besides this, adhesion of the different planes or layers of the cerebral substance to each other in a certain number of cases. " If the simple redness, the perceptible tume- faction—if the general and partial softenings, the increased resistance which we have noted in acute cases, left any doubt of the true nature of the organic disorder, the adhesions observed so often in chronic cases certainly admit of none ; and we are forced to allow that there exists in the brains of lunatics a state of true inflammation, unless we cease to regard the adhesions observed in other parts as undoubted traces of such a state, s and refuse to admit that adhesions of the pleura, peritoneum, and pericardium, afford evidence of the former existence of pleuritis, peritonitis, and pericarditis. " As the different traces of inflammation are more constant in the brain than in the membranes, it is necessary to conclude that the essential change c has taken place in the brain, and that the change produced in the membranes is only accidentally complicated with it." In his remarks on this subject, M. Foville plainly means to express his : dissent from the opinions maintained by M. Bayle, who, in his treatise " Des Maladies du Cerveau," attributes insanity to disease of the membranes. Among the morbid appearances of the brain, the varied changes of the cortical substance are the most constant in connection with symptoms of mental derangement. Although M. Calmeil maintained a different opinion, and was inclined to ascribe paralysis or the loss of muscular power to disease of the cortical substance, the facts on which he founded this inference do not, as M. Foville contends, warrant such a conclusion. In all instances of the general paralysis of lunatics which he has examined by dissection, there was, besides the change in the cortical substance, some alteration, either hardening, serous infiltration, or softening of the white substance ; and in most cases, in addition to these appearances, there were adhesions of the principal planes of the cerebral substance to each other. A very remarkable ca?e which occurred in the clinical course of M. Esqui- rol in 1823, affords strong evidence in favour of M. Foville's argument. The cerebrum of an idiot displayed the grey substance of both hemispheres ill the last stage of atrophy and disorganization, while the white portion of the brain remained perfect on one side. In this person the intellect had been entirely defective, but the muscular power on one side only had failed. From, this, and similar observations, M. Foville concludes tuat the function of the cineritious portion of the brain is essentially connected with the intellectual operations, and that of the fibrous or white struc- ture with muscular action. His two principal inferences are expressed in the following terms: 1st. Morbid changes in the cortical substance are directly connected with intellectual derange- ment. 2d. Morbid changes in the white substance are directly connected with disorders in the motive powers. The remarkable accuracy of these researches throws a strong shade of doubt, and even of im- probability, over those recorded cases of maniacal disease in which no morbid traces were discovered in the anatomical examination. There is much reason for suspecting that a more exact scrutiny, and a careful comparison of the state of the parts with the appearances displayed by the same organ in a natural and healthy condition, might have led, in some of these instances, to the detection of morbid lesions, greater or less in extent. Yet it is not improbable that degrees and modifications of maniacal disorder have taken place, in which such changes might have been, in an early stage, hardly to be traced with certainty. In cases of insanity displaying no general disturbance of the intellectual operations, and principally consisting in a morbid state of the temper and affections, and in tecent examples of monomania, we should not expect to find strongly marked changes in the brain, and there is indeed but little proof that the brain is in some of these cases diseased. And where there is more considerable disorder in the functions of the brain, arising secondarily or by sympathy with the state of other organs, the traces of such disorder may be very evanescent. It has likewise been remarked by M. Foville, that in some accidental affections of the maniacal class, succeeding the action of debilitating causes, as in the puerperal state, nothing has been discovered in the brain more striking than its extreme and gene- ral paleness, and, that although there are in these instances 60tne mottled appearances of a light red or rose colour on the cortical substance, such changes are too slight to be considered as idiopa- thic. The same writer adds that in the small number of cases of this description which he has had an opportunity of examining, the disorder in the brain has appeared to him to be sympathetic of some deeply-seated disease of the uterus or abdomen. In general, however, the fact is un- questionable that insanity depends upon organic lesion of the brain, and we have sufficient reason to conclude that this lesion is, in its commence- ment, a degree or modification of inflammatory action. Sect. VI.—Treatment of Maclness« Division of the Subject.—Moral and Medical Treatment.—The proximate or immediate cause of mental derangement is so much concealed from our research, the phenomena of the disease are so complicated, and the morbid states of the constitu- tion with which they are connected so various, that we might foresee no ordinary difficulty in the attempt to lay down, with respect to this class of disorders, any general principles or indications of cure. In reality this task has been found to be a more arduous one than even tlte circumstances adverted to would have led us to anticipate ; and hence many writers have given it up, and rest satisfied with stating as merely experimental re- sults the effects which particular remedies have been thought to produce. It is usual to divide under two heads the differ- ent means which suggest themselves to our con- sideration for the cure of madness, and to take up 56 INSANITY. separately what relates to the moral treatment of the insane, o»the means supposed likely to exer- cise a beneficial influence on the mind ; and, secondly, the medical or therapeutical remedies, properly so termed. As this mode of arrangement is attended with some advantages, and as no prac- tical objection has been raised against it, we shall keep it in mind in proceeding to the subject now to be considered, beginning with the medical or therapeutical treatment of insanity. Medical Treatment of Insanity.—The medical treatment of insanity may be referred in a great measure to two indications or principles, which in many cases may be followed more or less fully, and will in general serve the purpose of associating in the mind the different curative attempts which may be made with some hope of success. There are, indeed, instances of the disease to which these in- dications are either inadmissible, or can only be adopted in a very limited extent; but such cases may be considered as exceptions. I. The first indication is to remove or lessen that diseased condition of the brain on which we have reason to believe that madness is, in some part at least, dependent. That the diseased condition of the brain here referred to is nearly allied to inflammation, that all its essential pathological characters are those of inflammation, may be concluded from the fol- lowing considerations. 1. The morbid appearances displayed by ana- tomical researches in the brain and its investments are, as we have seen, generally referable to the immediate results or more remote vestiges of in- flammatory action. On this head we shall add nothing to what has already been said in the last section, and refer the reader particularly to the facts there accumulated, and the concluding re- marks upon them. 2. The relations of madness to other diseases, which are known to be connected with increased vascular action, or at least with increased fulness in the vessels of the brain, tend to support the same inference. The connection of apoplexy and paralysis, of epilepsy and of other cerebral diseases, with madness, has been pointed out by medical ! writers. These diseases are occasionally converted into each other, or mutually succeed each other, and undergo alternations. They display such a relation as leads us to believe that the proximate causes or the morbid changes on which the symp- toms immediately depend, are in all analogous. Therefore, as some of the class, apoplexy for in- stance, and paralysis, are connected with vascular fulness in the brain, it is hence probable that a state not far removed from this, and at least likely, under the influence of slight causes, to pass into it, gives rise to the phenomena of madness. The metastasis of inflammatory diseases from other parts of the body, among which is included the recession of cntaneous eruptions, is well known to be followed not unfrequently by the appearance of maniacal symptoms. Suppressions of catamenia and other discharges, giving rise to similar dis- eases, strongly confirm the same pathological prin-' ciples. 3. The causes in general which excite madness bring us to the same conclusion. These are prin- cipally of a description likely to give rise either to inflammation in the brain, or to a full and distended state in the vessels of that organ. Exposure fa severe heat or cold, insolation, concussion or othei injuries of the head, intoxication, and generalh, excess in the use of stimuli, great mental excite ment, are all of this class; the condition of the brain, which it is the tendency of these agents to promote, is either inflammation, or something bordering upon it. These different considerations concur in render. ing it probable that the actual condition of the brain which immediately gives rise to the pheno- mena of madness, is in general one of high vasculai excitement or turgescence, a state which, if it do« not really constitute inflammation, is at least closely bordering upon it, and so liable to pass into it, thai all the usual consequences of inflammation in many instances arise from it. But though we may be correct in drawing this inference as a general one, there are great difficul- ties to be overcome, and much remains to be proved, before we can be authorized to insist upon it as universally applicable. The phenomena of mental disease are so various, and even so diverse, that they may be thought, not improbably, to arise from very different states of the system. There are instances of mental disease conjoined with so much atony and debility, subsidence of vascular action, coldness of surface, and diminished secretions, as to indicate a very different state from that of in- flammation. Anatomical researches display in these instances a pale discoloration of the brain, with abundance of serous fluid, softenings of sub- stance, and other phenomena of a similar descrip- tion. Here we trace a state different from inflam- mation, though perhaps its remote consequence." Are there not, likewise, cases in which we are scarcely authorized to conclude that any disease of the brain has ever existed 1 Instances of moral insanity, in which obliquity of character exists through life, and scarcely ever amounts to aberra- tion of intellect, and some cases of monomania, in which slight and transient hallucinations super- vene upon moral obliquities of the same description, and appear at intervals, cannot perhaps be referred with any degree of probability to an active state of disease in the encephalon. It is probable, on the whole, that such exceptions bear a small proportion to the number of cases lo which the preceding remarks on the pathology of madness are applicable. If these remarks are well founded, they lead at least to one practical indication for the general treatment of madness. In proceeding with the medical treatment of maniacal diseases, we shall do well to bear constantly in mind the probable condition of the brain, and to direct our practice more or less with a reference to it. Yet we must not omit to observe that the phy- sician who proceeds to treat cases of madness as instances simply of inflammation in the brain, and who expects to cure it at once, like any other local inflammatory disease, by the direct operation of antiphlogistic means, will very often find himself greatly disappointed. He will meet with many cases_m which no perceptible henefit arises from bleeding evacuations of al! kinds whether general or locally applied, and combined with the whole series of remedies supposed to be required by the INSANITY, 57 existence of organic inflammation. Many patients will sink under such a course of treatment if car- ried on incautiously: it will leave the disease un- diminished, and exhaust the powers of life. This depends, perhaps, on the influence of diseased states in other structures and organs, or on dis- ordered functions of other parts which are compli- cated with, and in some instances give rise to, the disturbances existing in the brain. Inflammatory excitement is a part of the disease, but does not entirely constitute it, even in so far as the brain is concerned. Perhaps we may venture on the assertion, that there are few instances of madness in which the practical indication arising from the view which we have taken of the pathology of this disease will not be found applicable during some periods of the case, though in many its application is very limited. The degrees in which it is admissible are very various. In recent cases of mania, properly so termed, and of incoherent insanity, particularly in young and plethoric subjects, and where the disease has made its attack suddenly, and is accompanied with signs of considerable vascular excitement, much may be hoped from the antiphlogistic treatment, at least from certain parts of it judiciously modi- fied. We shall now consider the different means of which it consists, and advert to the opinions of some of the most eminent practical writers with respect to their use in cases of insanity. 1. Of Bleeding.—Cullen recommends bleeding in the early stage of madness. He says that it has been common to employ this remedy in all cases of recent mania, and, as he thinks, with ad- vantage. He observes that when the disease has subsisted for some time, he has seldom found blood- letting to be of service. " It is," he says, " a pro- per and even a necessary remedy in those instances of madness in which there is fulness and frequency of pulse, and when marks are observed of increased impetus in the vessels of the head." He prefers bleeding from the arm, while the patient remains in somewhat of an erect posture, and bringing on a degree of deliquium, which, he says, is a pretty certain mark of diminished fulness and tension in the vessels of the encephalon. Pinel, whose authority could not fail to produce an impression, is in this respect decidedly opposed to Cullen. He considers the signs of vascular plethora in the head, or of determination of the blood thither, as very deceptive ; and although he allows bleeding to be in some instances capable of averting attacks of recurrent madness when they are anticipated, he carefully abstains from the use of the lancet after the disease has actually broken out. Care is always taken, he says, to question the relatives of patients admitted into the hospital over which he presided, whether bleeding has been practised, and if so, what were its results. " The reply always proves that the state of the patient has changed for the worse immediately after bleed- ing." Pinel held very firmly the opinion that bleeding, even in maniacal cases which are accom- panied by circumstances supposed to indicate ple- thora and local determination to the head, tends to retard recovery, to render it more doubtful. He is even persuaded that bleeding gives to the disease a tendency to degenerate into dementia or idiotism. Vol. III. — 8 The facts, however, which this distinguished au- thor adduces as proofs of his opinion, afford, as M. Foville has remarked, but very equivocal evi- dence. " Two girls," he says, " nearly of the same age and temperament, were admitted into the hospital (the Salpetriere) on the same day: one of them, who had not been bled, was cured in the space of two months; the other had undergone a copious bleeding. She sank into a state of idiotism, or rather of dementia, and did not recover the faculty of speech till the fifth month. Her perfect restoration took place at the end of the ninth month." Now, as most authors fix the mean du- ration of madness at the period of several months, and some at more than a year, this case of recovery at the end of the ninth month cannot afford a strong condemnation of the practice pursued. Another case, which the same author has adduced as affording evidence against bleeding, is not more conclusive in respect to the influence of remedies on the ultimate event of the disease. Yet the opinion of such a writer, founded as it was, at least by himself supposed to have been, on ex- tensive observation, ought not to be entirely dis- regarded because he happened to select but dubious illustrations. If bleeding occasions a state of collapse in the system, and is carried beyond what is necessary to reduce an over-excitement, a fatu- itous dejection of mind is likely, in some cases, to be the result. M. Esquirol coincides with Pinel in the opinion that the diseased state on which mental derange- ment depends, is sometimes changed for the worse by bleeding. He says that he has seen madness increased after an abundant flow of the cata- menia, and likewise after one, two, or three blood- lettings. In such cases melancholy dejection has passed into furious madness. Yet M. Esquirol approves of moderate bleeding in plethoric cases, and where some habitual sanguineous evacuation has been suppressed. He has often, with advan- tage, applied leeches behind the head or to the temples of patients who are subject to sudden de- terminations of blood towards the head. His favourite remedies in such cases were the use of a few leeches at a time, repeated as often as neces- sary, and cold applications to the head. To outweigh the authority of those writers who either condemn the practice of bleeding in mad- ness, or allow of its adoption in so sparing a de- gree, strong evidence is requisite, but such evidence we possess. Dr. Haslam says that bleeding is the most bene- ficial remedy that has been employed in madness, and that it is equally beneficial in melancholic as in maniacal cases. He limits its use to recent cases and plethoric habits, and directs it to be per- formed by the application of six or eight cupping- glasses to the shaven scalp. The quantity of blood to be taken must depend on circumstances. "From eight to sixteen ounces may be drawn, and the operation repeated as circumstances may re- quire." When a stupid state has succeeded to one of high excitement, Dr. Haslam considers bleed- ing as contra-indicated. But Dr. Rush is the most strenuous advocate for bleeding in maniacal cases. He lays the great- est stress on this remedy, and has perhaps carried its use to a greater extent than any other medical 58 practitioner of high repute. The arguments which use 01 t -»--£ f interferen he has given in support of the practice of large | to employ unadvisedly the memo depletion in madness are the following:—1. The force and frequency of the pulse, the sleepless and agitated state of maniacal patients. 2. The appe- tite being unimpaired in lunatics, and sometimes even stronger than usual, a plethoric state of the vessels easily arises in such habits. 3. The im- portance of the diseased organ, the delicate struc- ture of the brain, which prevents it from long supporting morbid action without being exposed to the danger of permanent disorganization. This danger/ he says, is much increased by the want of sleep, the cries and exclamations, and the con- stant agitation of mad persons. 4. The want of any natural channel of discharge from the brain, by which the ordinary results of inflammation might be averted or got rid of, in that way by which serous discharges in other parts relieve the inflammatory state. 5. The accidental cures which have followed the loss of a large quantity of blood. Dr. Rush has seen several lunatics who had at- tempted self-destruction by cutting their throats, or opening the great vessels, cured by the abund- ant hemorrhages which have followed these at- tempts. 6. Lastly, he says that bleeding is indi- cated by the extraordinary success which has resulted from its use in the United States, and particularly at the hospital for lunatics in Penn- sylvania. Dr. Rush advises large bleeding at the first at- tack of mania. If the patient bears it without syncope, he ought to lose, according to this phy- sician, from twenty to forty ounces of blood. If possible, it should be taken from him while stand- ing erect. Free bloodlettings practised early in the disease have, as he says, a surprising effect in calming the patient, and in many instances are sufficient for the cure unaided by any other reme- dies. In most cases, however, bleeding from the arm is to be followed by the application of leeches or cupping-glasses to the head or nape of the neck, by low diet, antiphlogistic remedies, refrigerants applied to the head, and the use of warm or tepid baths. Dr. Rush was of opinion that the evacuation of blood ought to be carried to a greater extent in madness than in any other acute disease what- ever. From a patient, sixty-eight years of age, he caused two hundred ounces of blood to be drawn in less than two months. Another patient of Dr. Rush lost four hundred and seventy ounces by forty-seven bleedings in the course of seven months. We shall conclude this survey of the conflicting opinions of practical writers on the expediency of bleeding in madness, by the following observations of M. Foville, which are deserving of the most attentive consideration, and which in our opinion place the subject in the true point of view. He says, " Without ever having pushed the employ- ment of this remedy so far as Rush and Joseph Frank, I confess that it appears to me to be one of those on the efficacy of which the greatest reliance may be placed. MM. Pinel and Esquirol have proved that the ' expectant method,' assisted by a few simple rules, and a moral treatment wisely directed, have succeeded in a great many cases ; but although it is better to confine ourselves to the INSANITY. ~e of simple means, patiently continued, than Templey unadvisedly the method of interference, I belief that the physician devoted to the ud, of pathological anatomy can draw from the result, which it furnishes, compared with the observation of symptoms, valuable therapeutic inductions, that he may place reliance on their efficacy, and recommend them with confidence when experience shall have demonstrated their good effects. Are not the anatomical characters which so constant!, present themselves in acute cases, and the adhe- sions which are so frequent in chronic ones, ert dent proofs of inflammation 1 And hence, are we not authorized to hope for advantages from the use of antiphlogistic means ? » If it be added," says M. Foville, «that in se- veral hundred lunatics, whose bodies my situation for nearly ten years has given me an opportunity of examining, I have never found adhesions in acute cases, while they have been very common in chronic cases ; if, with these facts, the results related in the works of MM. Bayle and Calmeil are compared, we may conclude, on seeing these adhesions so frequent in chronic cases, that thej are incompatible with the regular exercise of an organ so delicate as the brain, and consequently incompatible with the return of reason. Hence we ought, in every acute case, to choose the most active means, in order to prevent this melancholy termination of the cerebral disease. " Such are some of the reasons which have led me to agree with several physicians who have been placed in circumstances favourable for making observations, that bleedings ought not to be en- tirely proscribed in the treatment of mental dis- eases. In the greatest number of cases of recent insanity which have been placed under my care, I have employed evacuations of blood, local or general, rare or frequent, abundant or in modera- tion, according to the strength of the patient, and the state of the pulse, the redness of the eyes, the heat of the head, the agitation and want of sleep. I have always preferred general bleeding, when there existed a state of plethora, which the force and frequency of the pulse evinced. In opposite circumstances, leeches on the neck, the temples, behind the ears, cupping upon the same part, and upon the shaved head, have produced decided benefit. Local bleeding having appeared to me to produce a marked effect upon the brain, I have often prescribed it at the same time with a general bleeding in the case where the intensity of the general phenomena has imperiously demanded the latter; but I have never rested exclusively upon the efficacy of sanguineous evacuations, although in many cases I have seen all the morbid symp- toms disappear, as if by enchantment, under their use. " I have under my care several patients sub- ject for a number of years to attacks of intermit- tent madness, which, left to nature, would last three or four months, or longer. " During three years, that is, since they have been confided to my care, they have not experi- enced a single attack of a month's duration. Often in the space of five or six days all the symptoms have been dissipated. General or local bleedings proportioned to the intensity of the symptoms, warm baths with cold applications to the head at INSANITY. 59 the same time, are the means by which I have constantly averted the attack. " I have several times prevented the return of these attacks by employing the same treatment, as soon as the redness of the eyes, the heat of the head, and wakefulness manifested themselves, even when there had been no delirium." The writer of the present article having super- intended during nearly twenty years a receptacle for maniacal paupers, has possessed adequate op- portunity of forming an opinion on the ground of his own experience as to the efficacy of different remedies, and among other practical questions with reference to the treatment of insanity, as to the extent to which bloodletting is advisable in this disease. The results of his own observation lead him to doubt the propriety of the copious bloodlettings of which Dr. Rush is the advocate. He believes the cases of madness to be compara- tively few, which can be cured at once by large depletions, and is sure that considerable danger to the existence of the patient would often be incur- red if such a practice were generally pursued. At the same time he is equally convinced of the pro- priety of moderate detractions of blood, as advised by Cullen, Haslam, and Foville. This remedy ought by no means to be neglected in cases of madness which have come on rather suddenly and with acute symptoms, unless some circumstance in the age, habit, or temporary condition of the patient, renders it unsafe. It is especially called for in young and in plethoric subjects ; when the disease is one of great excitement ; when there is constant agitation and want of sleep, and in such cases it should be adopted before these causes have induced exhaustion and collapse ; when there are marks of determination to the head, such as full and throbbing carotids and temporal arteries, red- ness of the face and conjunctiva, heat of the scalp, a contracted pupil, intolerance of light or of sound, headach, vertigo, startings, agitations, or convulsions. We are not to look for an aggregate of these symptoms before we prescribe bleeding, but more or fewer of them often occur to direct our proceedings. Less frequently we find the still stronger indications of which even M. Es- quirol allows the force as pointing out the neces- sity of bleeding. We allude to the circumstance that the disease has arisen from the sudden sup- pression of catamenia or of some morbid but, perhaps, also salutary discharge, from the disap- pearance of eruptions, or from the operation of powerfully exciting causes. Among these is the abuse of stimulating liquors. Madness, which is the effect of intoxication, requires antiphlogistic rem- edies, and bleeding cannot be dispensed with ; but care must be taken not to carry depletion too far in cases arising from this cause which assume in some degree the character of delirium tremens. We have reason to believe that patients labouring under delirium tremens have been killed almost instanter by large bleedings, which had been ordered by practitioners who were unaware of the nature of the case. This, however, is a form of disease easily distinguishable from ordinary mad- ness resulting from intoxication. It is frequently advisable to bleed once or twice from the arm to the extent of fourteen or sixteen ounces, and afterwards, if the indicatory symptoms continue, to apply cupping-glasses to the scalp, after it has been shaved, and repeat this operation or the ap- plication of leeches as often as the degree of ex- citement and signs of vascular fulness, the circum- stances of the patient otherwise admitting, seem to require. Many practical writers have insisted on the ne- cessity of bleeding in the early stage of madness, without adverting to the important advantages which are to be derived from the same remedy in the after periods of the disease. These, however, are highly important. The practice of bleeding to a small extent, either from the arm, or, what is commonly preferable, by cupping-glasses applied to the scalp or the nape of the neck, and repeat- ing the operation in some instances periodically when the tenor of symptoms has been nearly uni- form, or occasionally when the patient has been subject to fits of increased excitement, has ap- peared conducive to ultimate recovery in a great number of instances. When suppression of the catamenia or of hemorrhoidal evacuations has pre- ceded the attack, cupping on the sacrum or the application of leeches to the hemorrhoidal vessels may perhaps best supply the defect of the natural or habitual method of relief. The other resources, which are comprised un- der the antiphlogistic treatment of madness, will require a much less extensive consideration. Shaving the head should always be done when there is much vascular excitement and heat about the scalp. By the coolness afforded on the remo- val of the hair, more benefit and a greater degree of tranquillization is often produced than is antici- pated. Cutting the hair short is not sufficient: the head should be shaved once or twice a week. Blisters, setons, caustics, irritants of various descriptions, have been applied to the head and the nape of the neck in cases of madness, as well as in other diseases of the brain. While acute symptoms are present, with heat of the head and irritation of the general system, cold applications are preferable to blisters; but when these indications are not prominent, and when there is rather a tendency to stupor than excitement, blisters on the head are frequently of service. They have been applied in most cases to the nape of the neck with some advantage, particularly when, as it has often happened, the discharge which follows their application has been very considerable. M. Esquirol has remarked that blisters, cup- pings, and other irritating applications, are used successfully in cases which follow a metastasis; in monomania accompanied by stupor; in puer- peral madness ; and in dementia when not com- plicated with convulsions or paralysis. Issues and setons in the neck have been often tried, but the general result of experience is not favourable to their use. They afford little benefit in maniacal cases. In dementia connected with paralytic affections, they are more likely to be of service than in mania attended with excitement. In the ordinary chronic state of madness, these remedies are found to be rather injurious than beneficial. Irritating ointments have been applied in many instances, particularly since their use was strongly recommended by the late Dr. Jenner. Medical 60 INSANITY. practitioners have been generally disappointed in their expectation of benefit from this attempt. It is most likely to be successful, as hinted by M. Esquirol, in cases of metastasis. [It may be borne in mind, however, as a re- markable fact, that in the Gloucester Lunatic Asylum, England, which is under the superin- tendence of Dr. Shute and Mr. Hitch, the use of the lancet, leeches, cupping-glasses, blisters, dras- tic purgatives, and the practice of shaving the head are totally proscribed, and yet recoveries take place in a large proportion, and no cases of sudden apoplexy or hemiplegia have occurred. The practice of making an incision through the scalp, over the sagittal suture, with the view of establish- ing steady counter-irritation, has been employed for some years past by Dr. C. Evans, physician to the Frankford Insane Asylum, near Philadel- phia, in the treatment of chronic affections of the brain; and, it is said, with very satisfactory re- sults. The actual cautery and the Pommade am- moniacale of Gondret have likewise been applied with advantage. (See Counter-ikrttation.)] Cold Water and Bathing.—Cold shower-baths, and affusions of cold water administered in various methods, have been extensively tried in maniacal diseases. Dr. Rush considered them to constitute a very important remedy, and recommended, in order to obtain the greatest advantage from them, that they should be repeated two or three times in a day. M. Esquirol used this remedy with advantage in some cases; he chiefly prescribed it for young subjects. M. Foville says that he was a witness to an almost immediate cure of a ma- niacal girl of delicate constitution and nervous temperament, who was subjected by M. Esquirol to the affusion of cold water at the degree fourteen of the centigrade thermometer. She was placed, with a garment covering her, in an empty bathing- tub, and water was poured in small quantities on her head till it covered her body, and shivering ensued. On a second application of this method, which was for some time resisted, it was followed by deep sleep, accompanied by copious sweating ; and when the patient awoke, she was found to have recovered her reason. The method of bathing adopted by M. Foville in the hospital under his management is free from the inconveniences and occasionally injurious re- sults attendant on cold affusions. He places a cap or bonnet, containing ice and closely fitting, on the head of the patient, and keeps the body immersed in a warm-bath for two or three hours, and renews this proceeding twice or three times in a day, according to the intensity of symptoms. On adopting it, as he was accustomed to do at first, only once in a day, he found the tranquillity produced by it followed not unfrequently by in- creased agitation; but on repeating the bath, with the ice constantly applied to the head, he has fre- quently succeeded far beyond his expectation. It has been the apparent means of recovery in many acute cases, and has produced sleep and tranquillity in frequent instances of obstinate restlessness and agitation. The use of the shower-bath is often followed by re-action, when the patient, if excitable, be- comes violent. In old cases, attended with a dis- position to congestion of blood in the head, its use is precluded by the danger of producing r* ralysis. It is chiefly serviceable in young subjects; when the constitution is relaxed, and when it« predisposed to hysteric affections. Applications of ice, or, when more convenient, of cold water, are very generally serviceable n, cases attended with heat of the head and nntabi- 1 ^arm or tepid bathing has been found advan- tao-eous in the treatment of madness under a v* rie°ty of circumstances. A cold state of the skin, languor of the general circulation, indicated bj coldness of the extremities, a tendency to chronji eruptions, are among the phenomena which sug- gest its adoption. Sometimes it produces sleep after long-continued agitation. If the degree of heat be not such as to produce too much vascular excitement, it is generally an useful and safely applicable remedy. Purgatives.—No fact in medical practice has been longer established than the utility of purga- tives in madness; witness the fame of Anticyra and hellebore. To confirm a maxim so well sup- ported by the result of constant experience, it seems almost superfluous to adduce pathological facts. It is not, however, difficult to find this species of evidence in its favour. Many authors have remarked that spontaneous cure of madness has resulted from a supervening diarrhoea, in which the intestines have discharged in great quantities a variety of morbid secretions. M. Esquirol has well observed that purgative medicines ought not to be used indiscriminately in all cases of madness, and that they are injurious when the mucous membrane of the intestinal canal is in a diseased state. This is the case in many instances of insanity. We shall, under another indication for medical treatment, consider the method of practice which is advisable in dif- ferent states of intestinal irritation, as they occur in madness. At present it will be sufficient to observe that, unless any signs of disease exist in the structure of the alimentary canal, such as in- flammation or ulceration of the mucous coat of the intestines, the use of purgative medicines is one of the most important and generally availa- ble means for the cure of maniacal patients. The mildest cathartics are preferable to others in most instances, because their use can be long continued without injury to the structures on which they immediately act. The neutral salts, infusion of senna, rhubarb, jalap, castor oil, are in the majority of cases sufficiently powerful, and may be used daily or frequently according to circumstances. When there is decided tendency to constipation, or the alvine evacuations are morbid, calomel, scammony, colocynth, or croton oil, may be added, due attention being paid to the cautionary circum- stance above pointed out. Emetics.—Emetics nave been strongly recom- mended by some practical writers. M. Esquirol says that he has found them useful in most cases of melancholy accompanied by a torpid state of the system. Dr. Rush considered them to be chiefly indicated in hypochondriasis, or fewness of spirits connected with dyspeptic disease. Has- lam confirms their utility in cases attended with disorder of the stomach, merely with a view to the relief of that particular symptom, but he de- INSANITY. 61 clares that, " after the administration of many thousand emetics to persons who were insane, but otherwise in good health, he never saw any benefit derived from their use.'' " Perhaps no one," he says, " has enjoyed a fairer opportunity of witnessing the effects of remedies for insane persons than myself; and when emetics are em- ployed in Bethlem Hospital, they have the best chance of effecting all the relief they are compe- tent to afford, as they are given by themselves, without the intervention of other medii ines ; and this course of emetics usually continues six weeks." " It has been for many years the prac- tice of Bethlem Hospital to administer to the curable patients four or five emetics in the spring of the year ; but on consulting my book of cases, I have not found that such patients have been particularly benefited by the u companions may serve as a text to the practitioner ^ who wishes to act upon their imagination. The weariness of confinement, the desire of being at liberty, the wish of seeing their relations and friends, are so many means of drawing their at- tention outwardly: to be occupied with what passes around them, and in some manner to forget themselves, is a step towards recovery. However, .. there are cases where separation, as all other use- ful things, may be injurious to patients, when it is not modified with reference to the susceptibility of the individual, the character of his delirium, his passions, his habits, his manner of living. We ought never to lay down absolute rules in prac- tice ; the art consists in skilfully discriminating the circumstances which ought to modify general principles, whatever confirmation they may have derived from experience." The preceding observations of M. Esquirol have been confirmed, and in some particulars more strongly stated, by the late M. Georget. This in- telligent writer has remarked that all physicians who have habitually the care of lunatics have re- commended the seclusion of these invalids, in al- most every case, as the first condition, and one of the first means in their treatment. " Lunatics," he says, " ought to be separated from the objects which have excited their disease, or which foster or aggravate it; from relatives or servants whom they dislike, whom they pretend to command, and to whom they will never submit; from busybodies, who only irritate them by useless arguments or misplaced ridicule: they ought to be separated from society, and placed in an appropriate habita- tion, to ensure both the safety of the public and their own preservation. Their friends are always repugnant to put this plan into execution: a mo- ther, a wife, or a husband, can with difficulty be- lieve that the object dearest in the world to either Vol.. III. —9 f* of them can be better placed in the hands of strangers than under the influence of those who are eager to devote the most affectionate cares; they fear likewise that in lunatic asylums the sight of the patients will have a bad effect upon their friend, and aggravate the disease; that constraint, severity, and all kinds of bad treatment will be employed to manage the patients, and, if once cured, they will preserve a horriblp impression of their abode, and resentment against their relations who have consented to their confinement. These last considerations induce rich families to place their deranged relatives in private houses destined to receive a single lunatic, who is surrounded by servants and inspectors whom he does not know. Besides that these private establishments are very expensive, they rarely answer the end proposed ; either some relation chooses to remain near the invalid, or the latter soon perceives that every thing by which he is surrounded is destined for his service ; in either case the objects of seclusion are imperfectly attained. Lastly, many things are often required which are only to be found in pub- lic establishments. This imperfect separation, however, is all that can be adopted in some fami- lies, and we must make as much advantage of it as we can. In public asylums the seclusion is complete; the patients soon know that they are under the authority and even at the discretion of the director; they are watched and constrained without difficulty, under the care of regular at- tendants. They find powerful sources of occupa- tion and of distraction in associating even with the other patients. The greater number of lu- natics never discover that they are in the midst of mad people, and find nothing to complain of in this circumstance. When their reason begins to return, they are removed into the apartment des- tined for the reception of convalescents, and hence are withdrawn from sights which might make un- pleasant impressions upon them. As long as the disease continues, they are angry with those who have deprived them of their liberty ; but as soon as they have recovered their reason, resentment is changed into gratitude. On this account, then, the friends of the insane incur no risk. We do not pretend to deny that this separation and abode among other lunatics has occasionally aggravated the disease, when of recent occurrence, in some individuals: on the other hand, we affirm that the same means have cured many lunatics almost im- mediately. Besides it is next to impossible to preserve and take care of maniacs or monomaniacs in the midst of their family, and all the inconve- niences of separation disappear under the absolute necessity of its use." The same writer has briefly summed up the principal circumstances to which attention ought to be paid in the construction or choice and in the management of an asylum or house of reco- very for lunatics. He has collected these remarks from the writings of Pinel and Esquirol. " 1. M. Pinel has particularly insisted upon the necessity of classing lunatics, of separating such as are liable to injure themselves or others, and permitting those to associate together who may contribute to each other's cure. A lunatic asylum ought, then, to be composed of several parts more or less insulated. There should be a quarter ap- 66 INSANITY. propriated for each sex, a division for violent lunatics, a second for those that are tranquil, a third for convalescents, a fourth for lunatics who labour under accidental disorders. It will oe very useful to have a division for those who are of melancholy habits, and in a state of dementia, and another for furious and noisy patients, and for some lunatics who are of an untameable cha- racter, and are confined by way of punishment. It is above all things necessary to separate the sexes, the convalescents, and likewise those pa- tients who have depraved habits and indecent manners. Each division ought to have a court planted with trees, and, if possible, a garden for the patients to walk in. " 2. M. Esquirol, who has devoted his atten- tion to the arrangements which these establish- ments require for the convenience of the patients, to facilitate vigilant superintendence and attention, and to prevent accidents, is of opinion that such houses should be built on level ground ; that the cells destined for violent patients should be spa- cious, with a door and window opposite each other, and opening from without; that they should be boarded and not paved, furnished with a bed, firmly fixed in the wall; that all the cells should communicate with covered galleries or corridors, in which the patients may walk in bad weather, and by means of which the inspectors and ser- vants may easily traverse the different parts of the establishment; that all the rooms should be warmed by pipes of hot air ; that abundance of water should be furnished by fountains to wash the dirty cells ; that the privies should be sepa- rated in such a manner as to occasion no incon- venience to the patients; that there should be places appointed for a general work-room, for a common dining-room, for baths and shower-baths. In this plan of M. Esquirol's there are dormito- ries only for convalescents, melancholy patients, idiots, and individuals who are debilitated. For others little cells with one bed are preferable, in almost every case ; during the day the patients can go out and associate with others, and in the night they do not require companions. " 3. Beings deprived of reason, who fancy them- selves reasonable, who incessantly desire and de- mand things that cannot be granted them, and who are nevertheless sensible to kind as well as to bad treatment, must needs be difficult to influ- ence, to govern, and to cure. As long as each person continues insane, he looks upon the director and inspectors of the establishment as accomplices in the power which has deprived him of liberty, and upon the attendants as inhuman jailors. Even after his cure he is not always very grate- ful. The director, the inspector, and the attend- ants, will invariably be objects of prejudice, sus- picion, and hatred to the patients; they will re- ceive abuse and often blows from them. On the other hand, it is impossible for one who has not had for a long time the care of them, and studied their disease, to know the mental disposition of lunatics. Without such preparation we should attribute to wickedness what is the effect of dis- ease, or look upon lunatics as beings deprived of all sensibility. In either case we might be in- duced to treat them with severity. It is almost impossible to make servants understand that mad persons have the use of some of their facultin, with the exception of those servants who havi been themselves attacked by the disease. At the Salpetriere and the Bicetre great advantage is de- rived from employing persons who have been cured to take care of the patients. The physician of a lunatic asylum ought to be particularly care. ful to instruct the individuals who are to have tig management of the patients. <• 4. It is absolutely necessary that a judiciom arrangement of authority and subordination be established in lunatic asylums, and that the phj- sician be invested with a power superior to all with regard to every thing that concerns the pa. tients." The chief points on which the moral cure of madness turns are thus summed up by Jl Georget. « We may refer to three principal heads all the regulations that can be put in practice with refer- ence to the discipline and exercise of the mental powers in lunatics. 1. Never to excite the ideas and passions of the patients upon the subject of their delirium. 2. Never directly to oppose their unreasonable ideas and opinions, either by argu- ment, discussion, opposition, contradiction, or ridi- cule. 3. To fix their attention upon subjecti foreign to their hallucination, and communicate to their minds new ideas and affections by meam of different impressions. " According to the first principle, we should withdraw the patient from the causes which hate excited his madness, and even from objects whick might recall these causes, or suggest any allusion to them. Lunatics attacked with religious melan- choly should be deprived of their books of devo- tion ; they should not be permitted to engage in offices of religion. Those who are tormented with sexual desires render these desires more im- perious by gratifying them, if they do not destroy their health. We ought never to flatter the chi- meras of kings, of princes, of gods, of queens. We should never put the patients attacked with the fame kind of insanity together, because thej would talk incessantly of their conceits, and thus cause to each other a great deal of injury. Thm as in other diseases, we ought to leave the over- excited part at rest. " According to the second rule, we should nevei attempt to reason with lunatics in order to bring them to their senses, for their errors are necessa- rily connected with their disease. The most evi- dent proofs are of no weight upon the mind of i lunatic. He will suspect that there are secret reasons for deceiving him. Discussion, opposi- tion, contradiction, irritates the disease, and in- spires defiance and hatred. In accordance with the third rule, we should make it a point to oc- cupy the mind, and to direct it by different means, such as exercise, work, play, the society of other patients, sane persons presiding over them; by music, reading, conversation, the visits of friends, &c. We should oppose one passion to the ruling passion, and on some occasions excite the activity of feeling by strong emotions, by means of fear, or the sudden announcement of bad news, flu' these different means are applicable neither in every case nor at every period of the disease. B is in general very difficult to turn for any lengtJ INSANITY. 67 f time the attention of the patients from the sub- ect of their delirium ; it is above all things diff- icult to engage them in occupations either of vork or amusement. Very often the disorder of heir minds is such that they are continually inder the influence of their delirium ; they exist n their illusions, and their attention is hardly irrested by the objects that surround them. Re- toration to their friends should never take place nitil the convalescence of patients is perfectly istablished, and even then great precautions must >e used to manage the first interview, to prepare he mind of the patient and of the relatives, and o fix the subject and length of their conversa- -ion. " An active and constant inspection exercised >ver the patients and the attendants is very ne- cessary in a lunatic asylum. Patients who evince i disposition to suicide should never be lost sight )f for a single instant, whatever they may say or lo to obtain their wish. It is often necessary to confine violent patients with the strait-waistcoat. Those who are addicted to indecent practices,— i circumstance by no means infrequent,—should oe restrained by similar means. Occasionally it ^s better to confine them by shackles on the legs, fastened down in an arm-chair, or shut up in their 'rooms, according to circumstances. The use of chains is almost entirely abandoned, and we are indebted to the noble efforts of our venerable Pinel for this improvement in the lot of lunatics." Tit may be observed that M. Foville ascribes to the Quakers who have managed the " Retreat" the credit of having been the first to discard these inhuman instruments of restraint.) " At the time of the abolition of chains at Bicetre, M. Pinel observed that the diminution of the number of furious lunatics, and the accidents which they occasioned, was very remarkable. The only mea- sures of punishment that ought to be put into practice are the strait-waistcoat, seclusion in a cell, removal from one division to another, the shower-bath, and some occasional privations. A violent or wicked lunatic, who all at once puts on a menacing appearance, or even commits repre- hensible actions, should be immediately surrounded by a number of attendants, approached and seized at the same time on all sides, particularly by those who are behind him. Sometimes great advantage has been found by suddenly enveloping the pa- tient's head in a napkin, which completely bewil- ders him. In other cases, while persons placed before the patient endeavour to occupy his atten- tion, others advancing from behind easily lay hold of and secure him. [Of late, it has been proposed, and practised, to abolish totally all personal restraint in the manage- ment of the insane; and the course is said to have been entirely effective. The plan is to substitute a rigid system of constant superintendence, of well-preserved classification, and of humane and effective practical management. It has been affirmed, indeed, that in a properly constructed building, with a sufficient number of suitable attendants, " restraint is never necessary, never justifiable, and always injurious in all cases of lunacy whatever." Cases, in which the patients render their clothes and persons filthy, present considerable difficulty, but a warm bath is always ready, into which the patient is put, and well washed, and the clothes are changed as often as becomes necessary. In violent cases, the patient is at times placed alone in a room, well aired and lighted, where there is nothing destructible, and is treated with all the kindness that can be be- stowed upon him. If we admit, however, the practicability and efficiency of the system of non- restraint in a large mass of cases, it may be questionable, whether it be of universal applica- i tion; and were it so, it can rarely happen that establishments for the insane are so well provided with competent attendants, that corporeal restraint can be wholly dispensed with. The experience, however, of the large insane establishments of this country, has sufficiently shown that it can be but seldom necessary. By a proper classification of the insane, it will be found that there are comparatively few who are incapable of participating in labour or amuse- ment. Every well-devised insane asylum ought, therefore, to be able to employ such of the patients as are fitted for the task in agricultural or horti- cultural labours; workshops should be provided, and employment of some kind or other be care- fully adapted to each individual. The attention, which such occupations require, produces a moral revulsion, and prevents the topic of hallucination from recurring, or, should it recur, from wholly engrossing the mind of the lunatic. This is now so well understood, that in the different insane establishments it is an object of solicitude on the part of the medical superintendent; and the re- sults have been most salutary. The reports of these institutions sufficiently testify to the inte- resting fact, that however perverted may be the reasoning powers, there are but few who are un- susceptible Of appropriate appeals, when judi- ciously made. Fifty years ago, it would not have been credited, that numbers have attended public worship in the chapels of those institutions, and conducted themselves with the greatest decorum," who in the halls were noisy, talkative, and pro- fane.] Sect. VII. — Puerperal Madness. This term is chiefly and most correctly applied to a form of insanity incident to puerperal women. By some writers, the same expression has been so extended in its meaning as to comprise that species of derangement peculiar to females who are debilitated by suckling, and which commences in general several months after child-birth. Symptoms of insanity occasionally display themselves during pregnancy, and under circum- stances which indicate that they are dependent on that state. These cases are rare in comparison with those which occur after delivery. M. Esqui- rol mentions the instance of a young woman, of very sensitive habit, who had attacks of madness on two occasions, each of which lasted fifteen days, having commenced immediately after con- ception. The same writer observes also that several women at the Salpetriere have become maniacal during the time of their pregnancy. Cases of puerperal madness, properly so termed, that is, coming on after child-birth, are by no means infrequent. M. Esquirol has related that among 600 maniacal women at the Salpetriere, 68 INSANITY. there were 52 cases of this description. In an- other report by the same writer, there were 92 similar cases among 1119 insane females admitted during four years into the above-mentioned hos- pital. M. Esquirol is of opinion that the propor- tion is still greater in the higher classes of society, since out of 144 instances of mental disorder, occurring in females of opulent families, the symptoms had displayed themselves, in 21, either soon after child-birth or during the period of lac- tation. Dr. Haslam enumerates 84 cases of puer- peral mania in 1644 cases admitted at Bethlem. Dr. Rush, however, reckons only five such cases in seventy, received into the hospital for lunatics in Philadelphia. There is no peculiarity in the phenomena of puerperal madness by which this disease is dis- tinguished from other examples of insanity. Dr. Gooch has remarked that " if a physician was taken into the chamber of a patient whose mind had become deranged from lying-in or nursing, he could not tell by the mere condition of the mind that the disease had originated in these causes." Those cases which are more properly termed puerperal, as occurring in the first period after child-birth, are generally of the character of mania, attended with excitement of the feelings and mental illusions; while the disorder which displays itself in women exhausted by suckling, is most commonly connected with melancholy depression, a tendency to which may generally be perceived in females who nurse their children too long, with reference to the strength of their own constitutions. Cases of the former descrip- tion occur within a short period, and most fre- quently within a fortnight after delivery. They appear sometimes to be occasioned by fright or other accidental causes of disturbance; some- times by errors in diet, or by premature exertions or excitements : in other instances they take [dace independently of any discoverable external cause. The patient passes one or two restless nights, ap- pears unusually excited and irritable, talks loudly and incessantly, and very soon betrays a disturbed intellect. The attack is often attended with febrile symptoms. This is the case especially, as Dr. Burrows has observed, if it takes place about the fourth or fifth day, when the secretion of milk is producing a new excitement. The state of the pulse is the most important symptom in reference to the nature and treatment of the case, as well as to the prognostic which is to be formed of its result. Dr. Gooch has laid particular stress on this circumstance, and he has extracted a valuable passage which bears upon it from the manuscript lectures of Dr. Hunter. " Mania," said this emi- nent practitioner, " is not an uncommon appear- ance in the course of the month, but of that species from which they generally recover. When out of their senses, attended with fever, like para- phrenias, they will in all probability die,- but when without fever, it is not fatal, though it (i. e. fever) generally takes place before they get well. I have had several private patients, and have been called in when a great number of stimulating medicines and blisters have been administered, but they have gone on as at another time, talking nonsense, till the disease has gone off, and they have become sensible. It is a species of mada, they generally recover from, but I know.of noujjj of any singular service in it." Dr. Gooch's comment upon this passage is ta remark, supported by his own observation, ft, there are two forms of puerperal mania: ones' them is attended by fever, or rather by a rapt pulse; the other is accompanied by a very mod» rate disturbance of the circulation. Cases of ti latter kind, which happily are by far the mos numerous, terminate in recovery ; the former an generally fatal. Terminations of Puerperal Madness.—?w peral madness terminates, in a great proportions' cases, either in death or in the recovery of reaso; Few instances, comparatively, become cases b permanent insanity. It is, however, very difficti to obtain accurate information on this subjed Dr. Gooch has observed that the records of h» pitals contain chiefly accounts of cases whirl have been admitted because they had been unim- ally permanent, having already disappointed ta hope, which is generally entertained and add upon, of relief by private care : the cases of shot duration, which last only a few days or week and which form a large proportion, are totalh overlooked or omitted in the inspection of hospisj reports. This remark accounts for the unfavooi- able nature of the results which are ohtairw from such tables as those given by M. Esquiri and others. By this writer, ninety-two cases art enumerated, of which fifty-five recovered, andiii died, leaving thirty-one as the number of incur* bles, that js, one in three. Of the fifty-five ret* veries, thirty-eight took place within the first months. Dr. Haslam says that of eighty-tin cases admitted at Bethlem, only fifty recovered leaving thirty-five as the number of incurabln Dr. Burrows mentions fifty-seven cases, of whit! thirty-five recovered, and eleven remained m- cured; of the recoveries, twenty-eight took plan within the first six months. Dr. Gooch has k marked that these tables throw but little light upon the real proportions of recoveries, and pre- sent a prospect unnecessarily gloomy and dis- couraging. He adds, " Of the many patient about whom I have been consulted, I know onh two who are now, after many years, disordered is mind, and of them one had already been so before her marriage." The question, on the solution of which there ii the greatest reason for anxiety in reference toss; particular case of puerperal madness, is, whethei it is likely to be fatal; because, if not fatal, then is great probability of ultimate recovery. The most satisfactory way of coming to a conclusion on this inquiry, in any individual case, is by th< prognostications which the particular symptom afford, and on this subject we can add little « what has already been said. The principal dangtf which menaces life, in cases of this description is a state of extreme debility ; the excitement ol the vascular as well as of the cerebral functions, is so great as to wear out the strength, already at» low ebb, and neither recruited by nutrition norbj sleep, and the patient sinks from exhaustion. El- penence has proved that a rapid circulation is* principal circumstance which tends to bring oc this state. A very frequent pulse is the mosi INSANITY. 69 s infavourable symptom. Long-continued resista- nce to sleep, and a state of complete restlessness, i*.nd the appearance of great weakness and inani- tion, give likewise reason for apprehension. If these '-:igns are not found, the mental derangement of J,he patient need not give occasion to very serious udarm. C. Medical authors have sought to found a prog- !>• mstic in puerperal madness on the estimate of the lisproportions which deaths bear to recoveries. This ■annot afford evidence on which so much reliance v-nay be placed as on the symptoms of individual ;• :ases. Out of the ninety-two cases mentioned by r- VI.. Esquirol, of which fifty-five terminated in re- covery, there were, as we have observed, six ...ieaths, and in Dr. Burrows's table of fifty-seven ;_::ases there were ten deaths. The former calcula- tion gives one death in fifteen cases, and the latter me in six. But the patients in the Salpetriere ^ire probably removed thither after the period in which the disease is most dangerous to life. There t must have been some circumstance tending to ex- plain the discrepancy in the above-mentioned re- ]:. suits. The proportion of deaths given by M. .Esquirol's table may be somewhat too low, but we ( are inclined to believe that the result afforded by . that of Dr. Burrows gives a greater mortality than 'the average number afforded by general experi- ence. Pathology of Puerperal Madness.—The pa- thology of this disease involves several disputed questions, which we must not pass over without stating them, although we by no means expect to furnish a solution that shall be satisfactory to all parties. The first inquiry is whether puerperal madness depends for its immediate or proximate cause on inflammation of the brain and its membranes. The arguments urged in proof of this opinion, are, in the first place, the result of anatomical ex- amination in cases of madness in general. We must refer to a former section of this treatise on ■■the necroscopical researches into the state of the brain in the bodies of maniacal patients, for evidence on this subject, and for proofs of the general infer- ence that inflammation, or a state closely allied to inflammation, is really the condition of the brain in cases of insanity. As puerperal madness is iden- tified by its symptoms with other forms of insan- ity, this analogical argument has evidently some weight until it shall be proved that this particu- lar form of mental derangement furnishes an ex- ception to the general fact. Secondly, the phenomena displayed by dissec- tions in cases of puerperal madness itself, have been thought by some to afford evidence in favour of the same conclusion. Unfortunately there is some discrepancy in the results of anatomical re- searches in respect to such cases. We have no extensive record of accurately related dissections, which might illustrate on a large scale the patho- logy of this disease. M. Esquirol says that he has examined the bodies of several patients who have died under puerperal mania, without being able to detect any morbid traces that pointed out the scat of the disease; and Dr. Gooch has given the details of a case, at the termination of which he says, in general terms, that although the body was examined by a very eminent anatomist, no vestiges of disease were discovered in the brain or elsewhere. In several other cases, however, de- scribed by the same eminent writer, it must be observed, that although the complaint had occurred in bodies already exanguious from uterine hemor- rhage and other exhausting causes, there were dis- covered on dissection thickenings of the dura and pia mater, sinuses full of blood, serum effused under the arachnoid membrane, hardness of the brain, and numerous bloody points, on cutting the substance of the hemispheres. Dr. Burrows has likewise referred to several cases in which there were marks of cerebral congestion ; and in particu- lar to one of Newman's dissections, in which the arachnoid membrane was quite firm, and nearly as thick as the dura mater. On the whole there is sufficient evidence that in general the brain of puerperal maniacs displays, in a greater or less degree, the phenomena which are accounted to indicate the presence of inflammation. The reasons which in the minds of some writers have over-weighed all the arguments furnished by these observations, are the following: first, that the disorder in question frequently attacks patients who are previously in a state of great exhaustion, and therefore thought unlikely to be assailed by complaints of an inflammatory nature ; and se- condly, that puerperal madness, as might be ex- pected from the circumstances under which it takes its rise, and the exhausted and debilitated state of many patients who are attacked by it, cannot be safely treated by powerful antiphlogistic measures, such as copious bleeding. " Are we," says Dr. Gooch, " to shut our eyes to the symptoms during life, to the effect produced by remedies, to the mode in which death comes on,—that is, with symptoms of exhaustion, and to the remarkable emptiness of the veins throughout the body; and because there was a little serum under the tunica arachnoides, and more bloody points than usual in the medullary substance of the brain, conclude that it was a dis- ease of congestion or inflammation, and that per- haps the patient died because she was not blooded sufficiently V This last part of the inference would, indeed, be much more than the premises would warrant; the question, what is, in a patho- logical point of view, the condition of the brain, becomes comparatively unimportant and almost a matter of mere curiosity, when the practical indi- cations are already given, and even become the data from which we are to deduce reasons as to the nature of the disease. Yet it must be allowed that the existence of inflammation is not disproved by either of the arguments advanced. The dis- ease supervenes on an exhausted state of the sys- tem, but so do many other inflammatory complaints. Pneumonic affections often attack women who have suffered much in childbirth from uterine he- morrhage, but we do not for this reason call into question the inflammatory nature of pneumonia. Neither are we authorised in asserting that the disorder is not inflammatory, by the fact that the patients labouring under it do not bear bleeding ad libitum. How many inflammatory complaints are there in which we cannot venture freely on the use of the lancet ! Dr. Gooch's observation is, in a practical point of view, of the highest value. Antiphlogistic and evacuant remedies must not be used without the greatest caution in cases 70 INSANITY. of puerperal madness; but the existence of inflam- mation in the brain and its membranes, when evi- dence of it is displayed in the characteristics of vascular fulness and other usual phenomena, is not disproved by this consideration. The theory of this disease, in reference to the nature of its constitutional and proximate causes, may be different in cases which occur at different periods ; and this is the more likely, because these cases vary in respect to their phenomena. In those instances of maniacal affection which occur during pregnancy, it is probable that the dis- ordered state of the brain or of the cerebral functions is the result of sympathetic excitement, which the vascular system, perhaps that of the brain in par- ticular, sustains from the peculiar state of the ute- rine functions. The well-known complaints con- nected with temporary excitement of the brain in some females at the period of the catamenia, the symptoms thence resulting, such as the returns of hysterical, epileptic, cataleptic paroxysms, or of hysterical and sometimes maniacal excitement of the mind, are pathological facts sufficiently illus- trative of the affection alluded to, and show it to be in accordance with other morbid phenomena. When madness comes on after childbirth, the pathology of the case is, perhaps, different from that of the affection now described. Dr. Gooch said, " the cause of puerperal mania is that pecu- liar state of the sexual system which occurs after delivery." He afterwards thought this account of the matter not sufficiently explicit. " What I meant was this; the sexual system in women is a set of organs which are in action only during half the natural life of the individual, and even during this half they are in action only at inter- vals. During these intervals of action they diffuse an unusual excitement throughout the nervous system,—witness the hysteric affections of puberty, the nervous susceptibility which occurs during every menstrual period, the nervous affections of breeding, and the nervous susceptibility of lying- in women. I do not mean that these appearances are to be observed in every instance of puberty, menstruation, pregnancy, and childbirth, but that they occur sufficiently often to show tha-t these states are liable to produce these conditions of the nervous system." He adds, " Dr. Marshall Hall thinks that the susceptibility of the puerperal state is to be explained by mere exhaustion, and does not at all depend on the influence of anything specific in the condition of the several organs at that time; but would an equal or greater degree of exhaustion at any time occasion the disease ? This is a question of fact which I should answer in the negative. I have seen patients who have been deranged in childbed, and who had recovered, at a future period much more exhausted by illness, and much more agitated in mind, without the slightest appearance of mental derangement." It would seem that we are here referred for an explanation of the maniacal affection which oc- curs soon after childbirth, to excitement produced by the state of the uterine system. A remark, however, which obviously suggests itself on this subject is, that the phenomena of puerperal mad- ness usually display themselves just at the period when uterine excitement is subsiding. If ever the , uterine functions, or the activity of the whole sys- tern of organs connected with them, is suspend^ it is during the time shortly following the pnef. peral period. We should not, at this conjuncton, expect the brain and the mind to be excited bj sympathy with organic actions, which are in tr in a state of temporary cessation. But the tj. pression, excitement of the sexual system, which is allowed to be too indefinite to convey a very precise meaning, may include the process of lac- tation. Perhaps it is to the irritation produced bj the secretion of milk that we are more particular!) to direct our attention ; for this secretion is a pari of the series of functions belonging to the sexual system. But here we only return to the popular notion, according to which the disorder depends on the flow of the milk. Such is the opinion ol old women and nurses in general, and it may be the true one. The relations, however, of puer- peral madness to the different processes which are set up or cease in the animal economy subsequently to childbirth, will be illustrated, if susceptible of illustration, by an exact observance of the periods at which this affection most frequently displays itself. The information obtained on this subject is not so complete as we might desire, but still it is of some value. Sauvages and other writers have recognised two different forms of mental derangement incident to lying-in women. One of them has been termed " paraphrosyne puerperarum," and is observed to succeed labour, immediately or within a day or two, before the secretion of milk can disturb the system, and independently of any lochial suppres- sion. " Tlrese attacks," says Dr. Burrows, who assents to the above distinction of varieties in the disease, " will sometimes go off under the opera- tion of a smart purge and an opiate, and may then be considered as merely accessions of deli- rium ; in other instances they are more perma- nent, and become fully developed instances of puerperal insanity. Sauvages' second species is termed «mania lactea ,-' and Dr. Burrows is of opinion that maniacal symptoms in reality make their appearance most frequently about the third or fourth day after childbirth, which countenances the notion that they are connected with the lacteal secretion. This writer, however, has very candidly referred to the evidence deducible from the tables published by M. Esquirol, although it is rather opposed to the opinion above stated. From these tables it appears that in the years 1811, 181*, 1813, 1814, eleven hundred and nineteen insane women were admitted into the Salpetriere, of whom ninety-two laboured under puerperal mad- ness : of these— 16 became delirious from the first to the fourth day. 21 from the fifth to the fifteenth day, which gene- rally includes the termination of the lochia. 17 from the sixteenth to the sixtieth day. 19 from the sixtieth day to the twelfth'month of lactation. 19 after forced or voluntary weaning. The result seems to be, as Dr. Burrows allows, that the disease is more frequently a consequence of delivery than of suckling. On the whole it appears evident that some cause more general in its influence than any one particular process must be referred to, if INSANITY. 71 we would explain the frequent occurrence of 'madness in pregnant, puerperal, and suckling females. A view of this subject which seems to us more illustrative of it, occurred to Dr. Ferriar, and has been thus stated by him. "I am inclined to consider the puerperal mania as a case of conversion. During gestation, and after delivery, when the milk begins to flow, the balance of the rirculation is so greatly disturbed as to be liable to much disorder from the applica- tion of any exciting cause. If, therefore, cold affecting the head, violent noises, want of sleep, or uneasy thoughts, distress a puerperal patient before the determination of blood to the breasts is regularly made, the impetus may be readily con- verted to the head, and produce either hysteria or : insanity according to its force and the nature of the occasional cause." That new determinations in the vascular sys- tem should ensue on the removal of one so long subsisting as that to the uterus during pregnancy, i is in accordance with a well-ascertained principle in pathology. The natural and healthy determin- ation under these circumstances is to the lacteal glands, but owing to various causes, either exter- i nal or of predisposition, morbid determinations : occasionally take place. Some women become phthisical at a very early period after childbirth, or rather the symptoms of phthisis develop them- selves at that time in a manifest form. Other con- ■ stitutional complaints aie apt to arise at the same period, according to the prevalent tendency of the habit. When the brain is susceptible, it is likely to suffer in its turn, and become the scat of local disorder, the manifestations of which are affec- tions of the mind. If we consider the frequent changes of disturbances occurring in the balance of the circulation from the varying and quickly succeeding processes which are carried on in the system during and soon after the periods of preg- nancy and childbirth, we shall be at no loss to dis- cover circumstances under which a susceptible constitution is likely to suffer. The conversions or successive changes in the temporary local de- terminations of blood which the constitution under such circumstances sustains and requires, appear sufficiently to account for the morbid susceptibility of the brain. The cases of mental disorder which occur in the later periods of lactation are, as it is evident from M. Esquirol's table, of two kinds. In one the disease supervenes on weaning, and probably has its origin in the subsidence of the lacteal se- cretion. There are other instances which appear to arise from the continued excitement and ex- haustion of the system consequent on suckling. This state of exhaustion takes place at different periods in different constitutions. Some women can continue to give milk without injury for years, but by others, morbid feelings are experienced in the space of a few months or even of as many weeks, and do not subside for some time after weaning. The writer of this article has observed very numerous instances of melancholy dejection with symptoms of insanity more or less strongly marked, which have displayed themselves in the protracted period of nursing, and in females who were evidently suffering from exhaustion. In one instance a lady, who on former occasions had com- plained of feelings termed nervous, and had been much indisposed when giving milk, was persuaded to continue suckling a child until the thirteenth or fourteenth month. She was then attacked by a maniacal disorder, which, though of a mild cha- racter, was very decided in its nature. Nearly a year passed before her mind was perfectly restored. Treatment of Puerperal Madness.—If we con- sider that the greatest danger to be apprehended for patients labouring under puerperal madness arises from a state of extreme exhaustion, that many women die from this cause within a short interval from the commencement of the disease, and that if they survive this period, the healthy state of the mind is in most instances restored, it will be evident that our chief endeavours must be directed to the present support of life. If we can maintain and restore the general health, and keep the natural functions in a state compatible with continued existence for a time, the disease of the animal system will in all probability subside. An- tiphlogistic and particularly evacuant remedies must be used very sparingly and with great cau- tion. 1. Bloodletting, as a general remedy for puer- peral madness, is condemned by all practical writers on whose judgment much reliance ought to be placed. M. Esquirol is decidedly opposed to it. Dr. Gooch's observations on this subject contain the best exposition of the rules which ought to guide medical practitioners as to the use of the lancet in cases of puerperal madness. He says, " The result of my experience is, that in puerperal mania and melancholia, and also in those cases which more resemble delirium tremens, bloodletting is not only seldom or never necessary, but generally almost always pernicious. I do not say that cases never occur which require this remedy ; no man's experience extends to all the possibilities of disease, but I have never met with such cases, and I would lay down this rule for the employment of bloodletting—never to use it as a remedy for disorder in the mind, unless that dis- order is accompanied by symptoms of congestion or inflammation of the brain, such as would lead to its employment though the mind was not dis- ordered. Even here, however, great caution is necessary ; local is safer than general bleeding. In one case the head was hot, and the face red, and the pulse was said to have become somewhat hard, yet a bleeding of eight ounces was followed by extinction of the pulse within three hours, and death in less than six. The only cases attended by a quick pulse which I have seen recover were those in which no blood was taken. In the really inflammatory disease of the brain, bloodletting of course is essentially necessary ; but these, I think, can never be mistaken for puerperal insanity ; they are febrile headachs, more or less acute. Pain of the head with fever is a much better indication for bloodletting than disorder of the mind without these symptoms." 2. In cases attended with much heat about the scalp, flushing of the face, and strong pulsation of the temporal and carotid arteries, it will be proper to shave the head and keep it cool by means of cold lotions, or an oil-skin cap filled with ice or iced water, or by evaporating lotions. 72 INSANITY. If the symptoms above mentioned and those of mental excitement are very acute, and the debility of the patient is not in an alarming degree, a few leeches may be applied with advantage. Blisters to the occiput or nape of the neck are often ser- viceable ; they are much recommended by practi- cal writers. When the scalp is not hot, and the tendency of the disease is rather to stupor than to a high degree of excitement, blisters are usefully applied over the top of the head. The lower extremities, which are often cold, should be frequently immersed in hot water, or a hip-bath used. Dr. Burrows recommends bathing the legs and feet in a warm infusion of mustard or horse-radish. Heat should be applied in the most convenient form, and the circulation in the extremities promoted by other obvious means. 3. Purgatives and emetics are among the most useful remedies in this disease. The alimentary canal is frequently in a disordered state, the tongue furred, the breath fetid, the skin discoloured, the evacuations dark and offensive. A few brisk purgative doses, calomel followed by castor oil or rhubarb and magnesia, should be given in such cases. Emetics of ipecacuanha, with small doses of tartarized antimony, are very valuable remedies in this state of the alimentary canal. Dr. Gooch has remarked that they should be used with cau- tion when the face is pale, the skin cold, and the pulse quick and weak; and in general he prefers ipecacuanha to antimonials. 4. After these evacuant remedies have been premised, great advantage is frequently derived from the use of opiates. Full doses are generally attended with the best success. Ten grains of Dover's powders may be given at night, or a grain and a half of solid opium, or thirty drops of the tincture. Several writers recommend Battley's solution of opium in preference to the tincture; perhaps the acetate and muriate of morphia are the best preparations of opium ; they may be given in doses of a quarter or half of a grain, and re- peated every third or fourth hour until sleep is procured. When opiate disagrees, Dr. Gooch re- commends the use of hyoscyamus, mixed with camphor. He says that five grains of each should be given every sixth hour, and a double dose at night: a dram of the tincture will answer the same purpose. This writer is of opinion that narcotics are the most valuable remedy in the cure of puerperal mania; he says " that they often produce nights of better sleep and days of greater tranquillity, and this calmness is followed by some clearing up of the disorder of the mind." He says that these remedies produce salutary effects much more frequently in the mania of lying-in women than in maniacal disorders occurring un- der other circumstances; if, however, there is heat in the head, flushing in the face, and thirst, their use ought to be postponed until such symptoms shall have been removed. 5. In the more protracted cases of puerperal madness, tonic and stimulant medicines are some- times requisite, especially when the appetite has failed. Ammonia is much recommended. It may be given with infusion of cinchona or any bitter infusion. When it is not offensive to the stomach, the rectified oil of turpentine is one of the best stimulants, especially if taken in the dose of a drachm three times in a day with cinnamoi water, or any other aromatic fluid. 6. A rule of great importance refers to the dit\ of women in puerperal madness. It may, perhaps, be safely asserted that the greatest risk which pi, tients in this disease incur is that of being starved through the mistaken notions of their attendant!, who are too often disposed to consider the excite ment of maniacal disease a reason for withholding food, when this very state, owing to the exhaus- tion produced by its long continuance, renders! especially necessary to support the strength more carefully. Farinaceous fluids of a nutritive quality, milk, rice, and other such matters should be given at shoTt intervals, when febrile symptoms preclude the use of animal food. In most instances brot1] may be allowed and ought to be given. In the more protracted periods, solid meat, with malt liquors, should be taken. We have seen very many maniacal patients labouring under great weakness and exhaustion, with cold extremities,! clammy skin, passing sleepless nights, and under continual agitation, begin to improve as soon as their diet was changed, and meat with some ale or porter given daily. The pulse has become fuller and less frequent, the extremities warm, sleep has been restored, and convalescence has taken place in a surprisingly short period after such a system has been adopted. 7. The last observation to be made refers to the management of such patients. We must here advert to the remarks to be found in a former sec tion on the management and moral treatment of maniacal patients in general. The general rules only require modification in some particulars in relation to the peculiar circumstances of puerperal patients. The latter for obvious reasons cannot be soon removed from home. They require in other respects similar management. They should be separated from relatives and friends, and care- fully attended by persons who are fitted for the occupation by habit. It will not so often be necessary to send puerperal maniacs to lunatic asylums as deranged persons of a different descrip- tion. Sect. VIII.—Senile Dementia. Senile dementia is essentially distinct from in- sanity ; yet for various reasons that will be appa- rent, a short account of its phenomena will be properly introduced in this place. We have already described that species of fatuity which is the frequent result of protractel insanity. The term dementia has been adopted by late writers to designate this morbid state of the mental faculties. This expression, however, has been used in a somewhat more extensive sense, as equivalent to fatuity in general, and as denoting, besides the ordinary sequel of madness, various other morbid conditions, in which the in- tellectual powers are impaired or obliterated. It is applied to the fatuity which occasionally follows apoplexy, epilepsy, p;dsy, and other comatose dis- eases. By many French authors the same term has also been made to comprehend the mental disease or decay peculiar to old age. In its last stage fatuity displays nearly the same phenomena in every case, by whatever causes induced or by whatever previous diseases it may have been ushered in; but in the early periods, to which, INSANITY. 73 ^br reasons already explained, we purpose to limit the application of the term dementia, there are many shades of difference between its different forms. The intellectual weakness which follows * apoplexy is not precisely of the same character as that demented state which is the sequel of insanity, |'and which occasionally gives way either to a re- newal of maniacal excitement or to returning rea- son ; nor is either of these affections precisely "'analogous to the decay of mind incident to old "age. We must, in compliance with custom, con- tinue to use the received term, but we shall ''distinguish the last-mentioned affection by the additional epithet of senile dementia. The following is the description of dementia in ^'general which has been given by M. Esquirol. " Dementia deprives men of the faculty of ade- quately perceiving objects, of seeing their relations, "of comparing them, of preserving a complete re- ; collection of them; whence results the impossi- bility of reasoning correctly. Demented persons : are incapable of reasoning, because external ob- ii jects make too feeble an impression upon them ; hbecause the organs of transmission have lost a . part of their energy ; or, lastly, because the brain J« itself has no longer sufficient strength to receive stand retain the impression which is transmitted to r. it; hence it necessarily results that the sensations are feeble, obscure, incomplete: being unable to -■■form a true and just idea of objects, these persons r; cannot compare them, or exercise abstraction or - association of ideas; they are not capable of a sufficiently strong attention ; the organ of thought has not energy enough : it has been deprived of -- that vigour which is necessary for the integrity of its functions. Hence the most incongruous ideas succeed each other; independent of each other, ... they follow without order and connection; pa- . tients repeat words and entire sentences without , attaching to them any precise meaning; they talk, . without being conscious of what thoy say. It , seems as if unreal expressions were heard by them in their heads, which they repeat in obe- dience to some involuntary or automatic impulse, the result of previous habits or of fortuitous asso- ciation with objects which strike their senses." Senile dementia differs in many particulars from the state of disease just described, though in some others resembling it. There is in both cases the same speedy and almost momentary oblitera- tion of recent impressions, if the merely passive ' recognition of objects which present themselves to the senses may be so called. But in the dis- ease peculiar to old age it may often be observed that ideas which were long ago stamped upon the mind remain with nearly their original force, and are capable of being called up whenever associa- tion suggests them, or the attention is purposely directed to them. The impressions produced by present objects are often so slight and evanescent, and the notions connected with them are so con- fused and indistinct, that the individual affected scarcely knows where he is; yet he recognises without difficulty persons with whom he has long been acquainted, and if questioned respecting his former life and the transactions and pursuits of his youth or manhood, he will often give perti- nent and sensible replies. The disorder of his mind consists not in defective memory of the past, Vol. III.—10 a but in the incapacity for attention and for receiving the influence of present external agencies, which, in a different state of the cerebral organization, would have produced an effect upon the sensorium, or seat of sensation and perception. The following account briefly describes the state of a person labouring under senile dementia, who has been occasionally under the care of the writer of this article. It will serve to exemplify some of the foregoing remarks. A. M-------, aged about seventy years, was in his youth a farmer, but changed that occupation for the business of a baker, which he followed until he had accumulated property sufficient for his maintenance. He has been living for several years in retirement, and without any regular oc- cupation. His memory is said to have undergone a gradual decay. When he is questioned respect- ing present objects and circumstances, he gene- rally gives clear and distinct answers, but can sel- dom recollect what has occurred but a short time previously. In half an hour after he has been visited by his medical attendant, who is an inti- mate acquaintance, he will say, if asked, that he has not seen him for several days. His recollec- tion of persons whom he knew in the former pe- riods of his life, and of events which then hap- pened to him, is tolerably clear; but at times, and especially after sleep, he does not know where he now is. He sometimes fancies, at night, on waking from a short sleep, that he is engaged in his for- mer occupations. He has risen from bed, and set himself busily to prepare for lighting a fire in his oven, beats the wall, calls his men up, and asks if the fagots are ready. He cannot be persuaded without great difficulty that he is in-------street, and has nothing to do with the baking business. At other times he will get up in great haste to go down and see somebody who is waiting for him on business, or thinks that there is a horse stand- ing for him at the door, calls for his clothes, and wonders that his friends are so tardy in assisting him. At these periods his state is not that of or- dinary somnambulism. He sees and knows some at least of the persons who are about him, and will converse with them. He sometimes, during the day-time, wonders where he is, does not know the place though he has resided in the same house for some years. The hostess, who is an old ac- quaintance, at length convinces him that he is at her home. When his recollection is roused, and his thoughts are drawn into the right channel, he has a correct knowledge of persons, and shows not the slightest trace of maniacal illusions, or of anything approaching to the character of insanity. He is glad to see his old friends, shakes hands with them in his wonted cordial manner, is on the best terms with his relatives, and never displays the least deviation from the natural and habitual state of his feelings and affections. Senile dementia, or the decay of the mental faculties, is not the lot of old persons universally, though it is a condition to which old age may be said to have a tendency, and to which in the last stage of bodily decay some approximations are generally to be perceived. The change which time alone will perhaps sooner or later bring on, in those who long survive the allotted duration of man's days, may be accelerated by a variety of 74 INSANITY. circumstances. Among these is a life of too much activity and excitement, of mental exertion beyond what the constitutional strength of the individual is capable of supporting without con- stant effort; excessive anxiety and eagerness in the pursuit of business, or intense and unremitted application to studies of whatever kind. The minds and bodies of men are only fitted for exer- tion in certain degrees, which, however, differ in different individuals; but the powers of all are limited. All have need of occasional respite from labour, and the appointment of rest during one day in seven is, from physical considerations alone, calculated to promote the well-being of individuals and of society. We may observe that among those who neglect this ordinance, there have been many who have suffered the penalty in this life. Some have terminated a rapid and perhaps bril- liant career of unremitting and successful exer- tions by suicidal madness, of which too many and too well-known examples might be cited ; others, though in a longer measure of time, have accele- rated the period of intellectual decay. A second cause of senile dementia, next in the frequency of its operation to that which we have just mentioned, is the too liberal use of vinous or other fermented liquors. There are many persons who lead active lives, who are not considered in- temperate, yet drink on an average nearly a bottle of wine a day. Such persons, if their lives are not shortened, have every reason to expect a pre- mature imbecility. The same affection has been observed frequently to make its appearance in men long engaged in active pursuits, soon after they have relinquished their business or professions, and have laid themselves by to enjoy ease and leisure for the remainder of their days. The dis- ease often appears in a more marked and sudden manner in elderly persons who have sustained a slight-attack of apoplexy or paralysis, which has perhaps been speedily recovered, and expected to have left but slight traces of disease. That ex- pectation is verified so far as the sensitive and mo- tive powers are concerned, but the seat of intellect is found to have been shaken in its very centre. Senile dementia is entirely distinct from that species of moral insanity which appears occasion- ally, as we have already observed, in aged per- sons. The former is merely a loss of energy in some of the intellectual operations. It brings with it nothing morbid or unusual in the state of the feelings or affections, no tendency to de- praved or unaccustomed habits, nor, commonly, any change in the temper and general disposition of mind. Individuals to whose lot this complaint has fallen are seldom unhappy on account of it, and if they are in any degree aware of their con- dition, they bear it with patience and cheerful- ness. The state of the affections remaining natu- ral and unperverted, is indeed a general diagnostic between disorders consisting merely of impaired faculties, and the forms of madness. The reverse of the previous remark applies, as we have said in the former part of this treatise, to the various mo- difications of insanity, and probably in greater or less degree to every case which can with perfect propriety be designated by that term. This last observation, in its reference to senile dementia, may suggest a hint as to the justice and propriety of certain proceedings which are oce* sionally attempted and put in force with person labouring under that affliction. As madness a, only disorders the intellect, but likewise pervert the moral habits and the natural feelings of rj, afflicted individuals who are victims to it, arises hence an obvious and unquestionable priety in putting them under restraint. Theyi then not only placed under circumstances men favourable and sometimes essential to the cured their complaint, but are likewise prevented froo committing acts dangerous to themselves and other* and such as the same individuals would perhin have shuddered to reflect upon in the days of «» and unclouded reason. To act otherwise win them would indeed be the height of cruelty the case is widely different when the moral dispo- sition and the entire mental character remait unimpaired, and the memory only fails, or Ik aptitude to intellectual exertion alone is dimin- ished through the weakness of years. If an oli man, who has spent the greatest portion of hi life in active exertion, and has accumulated pn> perty by habits of labour and parsimony, aftei some time passed in retirement, begins to lose hi* recollection of passing events; if his faculties be- come impaired to a certain degree on account of that wealth which it has been the object of his lift to accumulate, and for the amassing of which bt has sacrificed all thoughts of ease and comfort during many successive years, he may now be- come the object of attack to some relative who may procure declarations of his incompetency tt manage his estate. If such a person is brought before a jury and sharply interrogated, examined in figures, and puzzled by a variety of question! respecting matters of business, and other topics requiring accuracy in dates and calculations, itii not impossible that the affair may issue in his confinement in a lunatic asylum, or that at all events the management of his person and bis affairs may be taken from the care of those to whom in the sound and entire state of his facul- ties he had confided both, and to whom, his moral affections and social feelings remaining yet un- changed, he still continues to be devotedly at- tached. In France it has been for many years not un- usual to confine aged persons of impaired faculties in the public hospices where deranged persons are admitted ; and this practice has so much prevailed, that M. Georget alludes to it as a source of error and embarrassment in the attempt to determine the relative frequency of madness in late and in former times ; these asylums being partly occupied by a number of old persons who remain till theii decease, and whose disorders are not properly cases of insanity. Previously to the year 1790, out of 411 persons admitted as labouring under disor- dered or decayed intellect, there were only 18 whose age exceeded fifty years, whereas, in 245! admitted between 1814 and 1821, not less than 880, or the third part of the entire number, were persons who had passed the period of life above mentioned. Of these, a great proportion were probably cases of senile decay. H uie custom of thus gett,r,g rid of aged parents were a matter of choice and in general practice, without excuse on the ground of necessity, we might doubt whether INSANITY. 75 t ar enlightened neighbours displayed their filial . iety in a more advantageous manner than the vlattas, who knock their aged relatives on the ead and eat them; or than the old Irish, who, as itrabo assures us, KaXdv ti tiyovvro KarurdUiv rows drepas Tt\tvTtj(javTas. But it is only among poor unities that the custom prevails, and it is but parallel to the habit of the poor in England, who iot unfrequently suffer their parents to die in .. iarish workhouses. It is the greatest evil attend- nt on iron-handed necessity, that it so often ireaks asunder the first and nearest bonds of duty " md natural affection. The following table will serve to illustrate the brms of disease which are included by medical ' vriters under the common term of dementia. It " s styled by M. Esquirol, from whom we extract t, a table of causes. The table exhibits the dis- ribution of 235 cases of dementia; the first cc~ umn contains the number of patients admitted at ':he Salpetriere during the years 1811 and 1812 ; the second column is the report of the author's -private establishment, and is limited to persons of the higher or more opulent classes of society. TABLE OF CAUSES. No. of Individuate. Physical Causes. Disorders connected with the ~i .. catamenia.............5 Critical period.............29 6 Consequences of childbirth ... 5 3 Blows upon the head........ 3 0 Progress of age............ 46 3 At ixic fever............... 1 2 Suppression of hemorrhoids .. 0 2 Mania....................14 4 Melancholia...............13 2 Paralysis ................. 3 2 Apoplexy................. 3 2 Syphilis and abuse of mercury 6 Faults of regimen .......... 0 Intemperance.............. 9 6 Masturbation.............. 4 7 Moral Causes. Disappointed love.......... 1 Fright.................... 4 Political excitement......... 0 Disappointed ambition....... 0 Poverty................... 5 Domestic griefs............. 8 192 73 >-195 40 235 It may be remarked in reference to the first column, that the cases placed under the heads, 1, 2, 3, 8, 9, 12, 13, 14, 16, 18, 19, 20, 21, amounting altogether to 102, were probably in- stances of insanity in some of its forms, or of the stages of fatuity which are its consequence. There only remain 60 cases, which appear to have been instances of dementia not preceded by madness. Of this remainder, 46 cases are examples of senile decay, and these appear to form the great majority of cases, which are referred by the writer above cited to the head of idiopathic dementia, or de- mentia, unconnected with insanity. It therefore appears that this class of diseases nearly resolves itself into the sequelae of madness, and the decay peculiar to old age. It is obvious that the art of medicine in refer- ence to senile dementia must be limited as to its sphere, in a great measure to the means of pre- vention, as cure is scarcely to be hoped. The prevention of this melancholy termination must, however, depend upon the habits of the indivi- dual, and on the mode in which the previous years of life may have been passed. In the regu- lation of previous habits may be found resources adequate in general to averting the approach of mental decay. Much will depend upon the man- ner of living during the early period of old age, or when the physical powers are beginning to de- cline. Habits of indolence, and those of too great mental exertion, should be alike avoided ; since many are observed to lose the vigour of their minds after a sudden and total retirement from active business, while in others the disordered state seems to have been brought on by too close application to studies, and particularly to those which require a sedentary life. The former of the causes above mentioned is, however, by far the most powerful and frequent in its operation, and numberless instances may be cited of persons who have exercised professions requiring consi- derable labour of mind during advanced years, without experiencing in consequence any decay of faculties. The preservation of health in old age, both in other respects and in what regards the functions of the brain, will depend, in a very considerable degree, upon the adaptation of diet and regimen to the constitutional state of elderly persons. With the alteration of habits which advancing age implies, with the various changes in the state of the physical functions which it brings with it, a corresponding variation in diet and regimen is necessary, and if this is not made, disorder en- sues. Many of the diseases incident to elderly persons are diseases of plethora, as apoplexies, and paralysis, and vertigo, and these are not un- frequently the preludes of dementia. The decay of faculties is observed to occur without such preludes in persons who live too freely. These and other considerations render it probable that the disorder of the brain connected with senile dementia depends upon a state of vascular reple- tion. When the disorders of old age have com- menced, by a comparatively spare diet, consisting principally or entirely of farinaceous and other light vegetable food, by discontinuing in a great measure the use of wine and fermented liquors, the general health, and that of the brain in parti- cular, will be greatly promoted. If there are de- cided threatenings of cerebral disease, an issue or seton, and the frequent use of mild aperient medi- cines to maintain a copious alvine discharge, will contribute to the same end, and will not only ward off attacks of apoplexy and palsy, but like- wise lessen the tendency to senile dementia. [The preparation of the above article suggested to Dr. Prichard his Treatise on Insanity and other Diseases affecting the Mind, (Lond. 1835,) which was reprinted in this country. It is a com- prehensive and able work, and may be referred to for further developments of the subject. See, also, Art. Insanity, in Copland's Dictionary of 78 INTUSSUSCEPTION—IRRITATION. Practical Medicine; Esquirol, Des Maladies Men- tales, Paris, 1838; and, for the arrangement, &c. of insane hospitals, Jacobi, Art. Irrenanstalten, in Encyclop. Worterb. der Medicin. Wissenschaft. xix. 62: Berlin, 1839; and On the Construction and Management of Hospitals for the Insane, with Introductory Observations, by Samuel Tuke, Lond. 1841. A good account of the American insane institutions is given in the First Report of the Insane Asylum at Utica, N. Y.; also, in the Eleventh Annual Report of the Trustees of the State Lunatic Hospital at Worcester, Mass. Bos- ton, 1844. (For the medico-legal bearings of insanity, see Mind, Soundness and Unsoundness of.)] J. C. Prichard. INTERMITTENT FEVER.—See Fever. [INTUSSUSCEPTION, (from intus, within, and suscipio—sus or sub and capio, to take.) In- tussusception or invagination of the intestines occurs when one portion of intestine passes into another. Owing to augmented peristaltic or spas- modic action of the intestines, an upper portion of intestine may be forced into a lower; or, should an inverted action of the intestines occur, it may happen, that the lower portion is forced into the upper, and becomes arrested there. The first of these lesions is called progressive intussusception; the latter retrograde intussusception. Invaginations are not unfrequently met with in the dead body, especially in children ; but these often occur, probably, as one of the last acts of life ; whereas, the invagination, that gives rise to the concatenation of phenomena termed ileus, is accompanied by an inflammatory process, which causes the adhesion of the peritoneal surface of the invaginated portion of intestine to the portion of the peritoneal surface of intestine with which it comes in contact, so that the intussusception cannot be reduced after death. Owing to the narrowness of the canal, and the resulting ob- struction, the phenomena induced by obstruction from whatever cause, or, in other words, those of ileus supervene. Intussusception may take place in any part of the alimentary canal; but it is most frequently observed in the ileum near where it terminates in the colon. At times, the invaginated portion sloughs away; and there have been cases in which as much as three feet of intestine have been- discharged per anum, with more or less of the mesentery attached. In thirty-five cases, col- lected by Dr. Thompson, (Edinburgh Medical and Surgical Journal, October, 1835,) the ave- rage duration of the disease was between four and five weeks. In twenty-two, the evacuated por- tion belonged to the small intestine; in the other, to the large, or to both. Where the invagination has proceeded to a great extent, or where the small intestines with the caecum have passed down into the sigmoid flexure of the colon, as in some cases that have been related, the seat of the dis- ease is manifested by a hard tumour; and in less marked cases careful examination has detected the existence of a deep-seated tumour. Treatment.—From the obscurity that must necessarily exist as to whether the phenomena of ileus be produced by intussusception or some other cause of intestinal obstruction, it is difHcuh to direct an appropriate treatment. Should it be diagnosticated, or suspected, cathartics must of course be very questionable remedies; and the only hope we can have is, that the invaginatei portion may be thrown off, and a cure be thus obtained; although such a result, it must be ad- mitted, is extremely rare. The appropriate gene- ral treatment, in all such cases, is that advised under enteritis (q. v.) ;—bloodletting, general o> local, or both, with full doses of opiates, the warm bath, &c. Metallic mercury has been recommended by most writers in intussusception, as well as in every case of obstruction of the bowels; but it is not easy to comprehend on what principle it has been advised in intussusception. If it be of the progressive kind, the mercury must proceed directly through it; and if retrograde, the same thing might happen, or, if not, by passing be- tween the intestinal and the invaginated portion, it might aggravate the disease. It has been supposed that large quantities of water or air thrown into the bowels might cause tho invaginated portion, in cases of progressive intussusception, to resume its proper position; and it has been proposed in suspected cases to in- troduce long bougies, and even pieces of whale- bone, into the rectum, with the view of pushing back the intussuscepted portion; but cases can hardly be imagined in which such agents can be appropriate. Emetics have been suggested in cases of progressive intussusception, yet they could only be of service before agglutination of the peritoneal surfaces has occurred; and, be- sides, one of the evidences of intussusception is the antiperistaltic action and vomiting. Under the same reasoning, cathartics might be advised in the retrograde form ! Where evidence has happened to be very strong as to the existence of intussusception and its seat, the operation of laparotomy has been advised, with the view of disentangling the invaginated intestiue; but it has been wisely discountenanced by almost all therapeutists. The symptoms of intussusception are always, indeed, obscure and doubtful, and may be produced by other states of the digestive tube; so that, if the abdomen were opened, it might be found that no intussusception existed; or if it did, that, owing to the agglutina- tion, no separation could be effected without causing, if possible, a more speedily fatal lesion. These circumstances, consequently, render the operation wholly inadmissible. Robley Dunglison.] IRRITATION.—It is remarkable that a term so commonly employed and so indispensable as this is, should never have received a definite and generally acknowledged application. The agents and subjects, the causes and effects, the influences and phenomena of disease, have all indiscrimi- nately passed under the name irritation, until the word has ceased to designate anything, and, " vox et praeterea nihil," is prostituted to pass off any obscure and unintelligible matter of patho- logy, for which more definite terms will give no quarter. If a case presents itself with bold and positive features, such as pain, convulsion, deli- IRRITATION. 77 num, palpitation, jarring pulse, and highly disor- ^ dered function, but without certain characteristics of inflammation, it is distinguished by some as irritation ; whilst others use irritation and inflam- mation almost as synonymous terms. If a per- son faints or dies under a surgical operation, or from a crushed limb, without hemorrhage, the result is ascribed to irritation: in another exam- ple, after the same accident, or the same opera- tion, fever arises, and the patient dies in raving delirium; yet this is also termed irritation. We do not venture to impugn the high author- ities that have rendered the term conventionally applicable to such varied and opposite affections ; but we would warn the student not to be misled * in his reading, by the etymology of the word ; nor to suppose that in the extended application which it has received from various writers, irritation means anything more restricted than a class of *• morbid states of very considerable variety. In further illustration of these remarks, and as an introduction to this subject, we shall extract some account of the views of irritation from the works of two distinguished writers, M. Broussais and Mr. Travers. M. Broussais ("Examen des Doctrines Medi- cales," and " Histoire des Phlegmasies Chroni- ques.") bases his description of irritation on the particular physiological views which he entertains respecting the vital properties of animal structure. These properties he calls sensibility and contrac- tility ; they are possessed in various degrees by the different tissues, and may be locally increased by certain circumstances ; such local exaltation always causing a diminution or depression of vi- tality in some other organ or system. This exal- tation of vitality is accompanied by an excessive afflux or congestion of fluids to the part, and con- stitutes what M. Broussais throughout his writings designates as irritation. The cause or circum- stances which produce irritation are of four kinds: —1. Excessive excitement by certain agents, call- ed stimulants or irritants, directly applied ; 2. sympathy with another irritated organ ; 3. the ab- sence of a stimulus which is habitual to the part; 4." repulsion of excitability from other part or parts. One of the most remarkable features of this doc- trine is, that irritation, when once formed in any part of the system, becomes a cause of irritation in other parts or systems ; the influence being propagated by sympathy through the medium of the nerves. The phenomena of irritation vary ac- cording to the part which it affects, but the afflux of fluids or active congestion, is common to all primary irritations, and this is prejudicial to the functions and regular nutrition of the part. The first seat of irritation is acknowledged to be in the nervous fibrils of the irritated part; and even in this stage irritation may be so intense as by means of the sympathetic effects on the system to cause death. But M. Broussais looks to the effects on the vascular system as the most important; and if he does not in his pathology describe irritation as vascular universally, his therapeutics certainly imply this ; accordingly the terms irritation and inflammation are used indiscriminately through- out his works. The irritation may be confined to the white vessels only, and then he designates it a sub-inflammation ; but this, as well as what is generally understood by inflammation, is included under the general term irritation. The increase of sensibility and contractility im- plied in irritation is sometimes shown by pain, convulsion, &c, but it is not always directly man- ifest, and is frequently not so, when irritation has its seat in the viscera, where a system of nerves exists which do not tiansmit sensations tothesen- sorium. Frequently the sympathetic irritations are more manifest than the original one that excited them. These secondary irritations or sympathies are of two kinds, organic, and those of relation. The organic consist in organic phenomena, such as increased action, congestion, disordered secre- tion, nutrition, temperature, &c. Morbid sympa- thies of relation arc shown by pain, convulsions of the voluntary muscles, and mental derangements. Any of these kinds of sympathy may be excited separately, but they more commonly coexist; and in proportion to their intensity and number will be the severity of the disease ; these generally de- pend on the sensibility of the organ primarily irri- tated, and of the system generally. Sometimes the original irritation continues to be predominant; the organ which it affects being the only one to suffer from congestion and disorganization; but occasionally it happens that a secondary irritation becomes the principal; this constitutes metastasis. Again, the principal irritation may be transferred to some organ of secretion or exhalation, and is relieved by a discharge from the system ; this is what is called a crisis. When irritation causes an accumulation of blood in a tissue, so as to pro- duce swelling, redness, and heat, it is called in- flammation, this being only an irritation of an in- tense kind, observing the same laws as irritations in general, except that when unrestrained it pro- ceeds more speedily to disorganization. These appear to be the main features of M. Broussais' doctrine of irritation in general. In describing its further application to particular diseases, he gene- rally uses the terms irritation and inflammation as synonymous, and ascribes to such an affection va- riously multiplied by sympathy and reaction, and occupying various seats, all febrile diseases, he- morrhages, profluviae, morbid growths) most of the nervous diseases, dropsies, and even occasionally scurvy itself. In all febrile diseases and consider- able inflammations, the heart is sympathetically ir- ritated, whence the quick pulse and hurried circu- lation ; but the main and most important seats of irritation, either primary or sympathetic, are the mucous membrane of the stomach and bowels, and the brain. In all fevers called idiopathic, these irritations are the primary evils: they are equally so in the exanthematous and some other diseases; and there is not an inflammation of an extent sufficient to quicken the pulse which does not sympathetically produce a decided irritation of these organs. The cerebral irritation is in most instances secondary to that in the stomach and bowels, and it always reacts on and increases the latter. Without proceeding further in the details of this doctrine, which Coutanceau has well named the doctrine of irritation, we may sum it up by saying that there is not a disease to which the human body is liable which is not dependent more 78 IRRITATION. or less directly on irritation generalization, it might be expected, would have been confined to the name only, and although it Such an excessive i action, referring all morbid phenomena and pro. ducts only, to excess or diminution ; to exclude from therapeutics the whole class of alterative^ should give a new aspect to pathology, it could and to exaggerate in numerous ki°J»°[^u"? hardly be anticipated that a corresponding inno- their stimulant (often unproved) above then vation would have been extended to therapeutics. But the case is far otherwise. Broussais, in as- cribing all diseases to irritation, and in viewing in that irritation nothing but a grade of inflammation, recognises truly curative means only in antiphlo- gistics, and denounces all other descriptions of remedy as irrational aud hazardous. Nor is he less exclusive in his catalogue of antiphlogistic remedies : purgatives and emetics he prohibits as dangerous irritants of the gastro-enteric mucous membrane, that soul and focus of all sympathies: diuretics irritate the kidneys; expectorants the bronchial membrane: diaphoretics the skin; and instead of counteracting the original disease, they may reflect on it a new and aggravating irritation: the same objection applies in most instances to blisters and epispastics in general. In short, the whole class of antiphlogistic measures is, with trifling qualification, reduced to bloodletting, absti- nence, and dilution. Whatever may have been the triumphant proofs of success appealed to by the sanguine advocates of this doctrine, we refer to the united experience of the enlightened practitioners of this country, we refer to the records of these pages, for abundant evidence that its absolute practical application would be dangerous and unnatural, and that to deprive medicine of the agents that it so sweep- ingly proscribes, would be to curtail the art of its most salutary aids. Nothing can more strikingly expose the danger of excessive generalization than a familiar and unbiassed study of nature in all the varieties of her powers; and in our opinion the philosopher who would ascribe all natural pheno- mena solely to gravitation or some such general power, would not be more partial and incompre- hensive in his views than the physician who at- tempts to restrict the still more complicated and diversified derangement of the animal body to an acknowledged but ill-defined principle, and to still further limit the practice of his art by a partial view of that principle itself. Great credit is due to M. Broussais for having fully established the fact, hitherto but little noticed, that local inflammations, particularly in the stomach and bowels, are present in most febrile diseases; that such inflammations are capable of producing grsat disorder and even inflammation in remote organs, by sympathy through the medium of the nerves; and that similar affections frequently complicate themselves with and aggravate many chronic diseases. The most salutary results have been obtained from the application of this knowledge to practice, in the judicious use of adequate anti- phlogistic measures wherever these inflammations subsisted ; and a more qualified and cautious pre- scription of purgatives and other medicines in similar cases is another good flowing from the same source. But to make the word irritation the re- presentative of the origin of almost every disease; to exclude from pathology all views of general morbid states, whether of plethora or inanition, excitement or depression; to refuse to acknow- ledge in local diseases any diversity of mode of evacuant or antiphlogistic effects : to disregard the operation of narcotics, antispasmodics, and othei medicines which exert a direct influence on the nervous system, and through it often favourably affect the vessels;—this is to deny ourselves the advantages of daily experience and unbiassed ob servation, and to render us the slaves of a system instead of the followers of nature. If M. Broussais were a little more impartial and considerate towards his own principles, and would take more into view that state of the nervous ty* tern which he acknowledges to be primary in the state of irritation, and which, as existing alone, may properly be viewed as an object of distinct and specific treatment; if he would admit thati certain state of the vascular system is required before the irritation can produce inflammation, and that, therefore, antiphlogistics are indicated only when this state is present; and if he would take into consideration the secernent and exhalant power as well as the inflammability of the vascu- lar system, and recognise the salutary operation of certain alterative, evacuant, and astringent medi- cines ; then his physiological system would stand on a broad and comprehensive basis, and its appli- cation to practice would be consistent both with principle and with the general experience of the most successful practitioners. But in its present state we cannot but view this doctrine as partial and exclusive : and we would decline his use of the word irritation as vague in pathology, and fallacious in therapeutics. The sense in which Mr. Travers uses the term is considerably different, but as he does not attempt to give a definition of it, it is difficult to render in a few words an explanation of his views. He seems to apply the name irritation to any disorder of sensation or function, whether of the nature of depression or excitement, that is not attributable to inflammation or to injury of the mere mechanism of parts. It is chiefly through the nervous system that the phenomena of irritation manifest them- selves ; and this constitutes the character which most distinguishes irritation from inflammation: but the relation of these two states of disordei must be as intimate as the connection between the nervous and the vascular systems is close and re- ciprocal. But it will, perhaps, more nearly repre- sent Mr. Travers' view of irritation to say that it is a morbid modification of the irritability of I part or system. Here we are naturally led to ift quire what irritability is, and what is its healthy proportion and mode of action. Of irritability it can only be said that it comprises the vital proper- ties of a part or tissue, and is shared in various proportions and forms, by the different organs and texture of the body. If there is any rule observed in the distribution of this natural irritability, it « not in the ratio of sensibility, vascularity, or mus- cularity, but rather according to the importance of the organ in the functions of life. It is much more largely possessed by some individuals than others; and various circumstances, external and internal, are capable of producing a great variety IRRITATION. 79 in its proportion in the same individual. An ex- cess or deficiency of natural stimuli, or the opera- Lion of noxious agents, will convert healthy into morbid irritability; and again, if the share of irri- tability possessed by an organ be morbid, natural stimuli will produce irritation. Thus an irritable stomach may be nauseated and disordered by many Ordinary articles of diet; an irritable bladder is continually parting with its contents before the stimulus of distension can be supposed to act: an Hnitable heart becomes tremulous and palpitating 'whensoever its action is excited; an irritable skin breaks out in a rash from many slight causes of cited state of the function. It is not unimportant to observe this distinction; and as the constructioj of our language does not admit of it in the wore] itself, we shall endeavour to restrict irritation to the latter meaning, and describe the other as tin irritating influence or act. Without attempting to explain them, it will be convenient to represent the living properties in general by the word irrita- bility, which merely denotes their relation in the abstract to irritants. There is a certain share of irritability natural to the healthy state of every part, and the moderate operation of natural irri- tants upon this, constantly induces that degree of irritation which constitutes healthy function. Irritation in a morbid state implies excess, which, when great, sufficiently declares itself by the dis- order or loss of balance that ensues; but in smaller degrees, morbid irritation is as hardly dis- cernible from healthy as slight disease is from health. Irritation may arise from an excess of irritability in a part independent of external circumstance^ so that the ordinary or habital stimuli become irritants; or it may proceed from an additional irritating influence from without. Thus vomitin| is a symptom of irritation of the stomach : and it may arise from excessive irritability of that organ, as in gastritis, and in the sympathetic irritations of the stomach from concussion of the brain, die- eases of the urinary organs, pregnancy, &c; H may on the other hand proceed from the additional irritating influence of an emetic or of indigestible food. So, likewise, irritation of the mucous mem- brane of the lower intestines may manifest itself by diarrhoea ; and this irritation may proceed from the over-irritating quality of the contents of thi intestines as in bilious diarrhoea, and the opera- tion of a drastic purgative, or from the excessive irritability of their membrane, as in dysentery, lientery, &c. Again, the urinary bladder showi signs of irritation when subjected to the unusual stimulus of gravel or stone; and the same phe- nomena are presented when, either from disease in its coats or by sympathy with some adjacent parts, as in stricture of the urethra and rectum, scirrhus uteri, ascarides, &c, the irritability of the bladder is inordinately increased, and it is con- tinually parting with its natural contents. This division of the modes of irritation is useful, inas- much as it points out a distinction which is some- times of the greatest importance in practice, but it is one that cannot always be made ; for the two modes frequently unite, and an excessive irritatin| influence very commmonly induces an unnatural irritability of the part to which it is applied., Thus, after an emetic or other irritating substance has been rejected from the stomach, the organ continues for a while morbidly irritable, and re- fuses to retain the blandest liquids ; and the blad* IRRITATION. 81 , der often remains irritable after all the gravel has r passed away. Again, when the irritability of a n part is low, what is commonly an irritant may ^fail to produce irritation. Thus an emetic some- | times fails to excite vomiting; crude and indigesti- ble food may pass through the stomach, and faces 'may accumulate in the intestines without injury; worms may inhabit the viscera, and gravel lie in the bladder, without any remarkable signs of irri- tation in the respective organs. The same re- ^markable difference in the susceptibility of irrita- Jvtion is observable in the same individual under ''different circumstances, and even simultaneously ^in different parts of the same system. To say that this susceptibility of irritation depends on the mach and bowels may exhibit irritation in pre. fuse secretion and inordinate movements, while! other secretory and motory organs are in a state of complete inactivity and prostration. The mamms and the testis sometimes present a form of irrii* tion in an excessive sensibility or constant pain, without any apparent excitement or weakness ig their vascular structure. It is in fact a degree of relative, not absolute weakness, that charac- terizes irritation through all its range of degrees. The excitement takes effect partially only, and the parts unaffected do not contribute to carry the orgasm through a series of processes by which it is at length exhausted, as in the case of inflam- mation ; but if the cause continues, the irritation may persist for an indefinite time, occasional more or less mischief and disturbance, according to the importance, in the system, of the balance which it destroys. In the greater number of in- stances of irritation, the vital powers are enfeebled; and this constitutional weakness is the reason why the excitement does not become general and pus to the state of fever or inflammation ; but abso- lute debility is not essential to the existence of irritation; since the most perfect inflammations and sthenic fevers commence with simple irrita- tion, and this is a stage in all cases of reaction The persistence or protraction of irritation cer- tainly implies relative, and in most instance!, general weakness; for the existence of power would lead either to general reaction and restora- tion of balance, or to the more powerful process of pyrexia and inflammation. The operation el the morbid virus received into the system through wounds in dissection strikingly illustrates twe modes of irritation. Its local effect is that of direct irritation, while its action on the systemfj that of powerful prostration, against which the feeble and irregular reaction of the vital forces de> velops another kind of irritation. If in such a esse inflammation begins in a part, it seldom exhibits the vigorous and decided character of healthy inflarf mation ; but occupying the capillaries principally, and unseconded by any energetic action of th other parts of the vascular system, it takes on ens erythematous form, while the effusions are serooe or sanious, destitute of coagulable lymph, the pls# tic effect of which tends to limit and restrain phlegmonous inflammation. The variety of signs which this complication of disorder may present is very considerable; but they principally de- pend on these two causes—the noxious or seda- tive influence of the poison, and the irritation re- sulting from an imperfect and irregular reaction of the vital powers against it. For a full and in- teresting detail of examples of this kind, we must refer our readers to the work of Mr. Travers, before quoted. We may, in conclusion, sum up the kinds of irritation under three heads:— 1. Those caused by direct irritants or stimtrH whether acting immediately on the part, or medi- ately through the nerves. 2. Those caused by a preternatural irritability, which, independently of any new exciting inflo ence, renders the relation of ordinary circumstances a source of irritation. 3. Those caused by indirect irritants, or thou IRRITATION o nfluences which, although in themselves pros- lb rating or sedative, become irritant through the Reaction of the vital powers against them. f( This division must be admitted to be in some v Measure artificial, inasmuch as few examples of J rritation occur in which one only of these kinds | ")f causes prevails. They, particularly the first Snd the second, frequently become engrafted on '■ >ne another, and occasionally all coexist; but still 5 he greater number ofcases are sufficiently stamped >y the prevalence of one or other of these kinds )f irritation, to render the distinction available in f iraetice. 1. Diseases of Direct Irritation.—Of this * rind is the disorder resulting from all sorts of 'slight mechanical injury, whether by contusion, super-extension, puncture, incision, or laceration ; '•» "rom extraneous substances, tumours, effusions, tnd accidental productions; chemical irritants, too ■ong retained or vitiated excretions; dentition, nudities, and worms in the alimentary canal, cal- culus in the urinary or biliary passages, and nany others. Irritation in all these cases is un- doubtedly the result of a reaction of the vital pow- n-.-jrs, the object of which is salutary, being the re- moval of an irritating matter or the reparation of : in injured part. Whether there be a state prior :o reaction which can bear the name of prostra- - :ion in these cases, as well as in those of the third : .Mass, is a matter of merely speculative and not prac- . tical interest, since we can detect in their history no other than a direct mode of irritation. The reparation of an injured part depends mainly on the vessels obeying the impulse of irritation : and ^unless there be a peculiar defect of power in them, the disorder passes into the more healthy state of ^inflammation. Where this defect subsists, there may be either the imperfect inflammatory action .which we see in erythema and erysipelas, or no inflammation at all, and then pain and disordered function or secretion are the signs which attend ...irritation. It is for the same reason that injuries „,of tendons, ligaments, fasciae, and other fibrous , .membranes, commonly exhibit more of irritation than of inflammation ; they are not liberally sup- plied with vessels, and the irritation, instead of "speedily terminating in the reparatory or suppu- .ratory process, lingers longer in the part, with pain, serous effusion, &c, sometimes exciting, sympathetically, severe constitutional derange- ment, and even tetanus. In the irritation result- ing from the application of mechanical or chemi- cal irritants, the salutary object of the reaction is more apparent. Thus, if a grain of sand or salt fall on the conjunctiva, the pain and irritation ex- cite a copious secretion of tears, the tendency of which is to remove the offending matter. Mucous membranes, when irritated, throw out viscid mucus to protect themselves. When a thorn or a needle penetrates the skin, an irritation is produced, :which tends to inflammation; this by effusion limits the irritation to the immediate vicinity, and :by suppuration removes the irritating matters. But, on the other hand, irritation may fail of its salutary end in all these instances. The grain of sand may remain lodged; the mucous effusion be inefficient as a shield; and the vascular power may be insufficient to effect the process of the expulsion of the thorn or needle; and then the irritation becomes a disease of more permanent character. So worms in the intestinal canal will irritate the membrane of the bowels in every va- riety of way but a salutary one. Thus they may affect the nerves, occasioning by sympathy grind- ing of the teeth, convulsions, disordered appetite, various pains, palpitation, &c. The vascular sys- tem may likewise be excited, and mucus poured out in great quantity, the peristaltic motion acce- lerated, without dislodging the offending bodies; whence diarrhoea, with tormina, depraved excre- tions, thirst, atrophy, and other constitutional dis- orders, may ensue. The same description will apply to scybalous faeces lodged in the cells of the colon. Indigestible food and excessive acid or acrid secretions in the stomach irritate it in a va- riety of ways : if the sympathies of the muscular apparatus related to it arc quick and susceptible, vomiting is excited, and the end of the irritation accomplished. But if these are not sufficiently roused, the irritation will cause other sympathies and uncomfortable feelings, both bodily and men- tal ; whence arise gastrodynia, pain in the chest, incubus, palpitation, asthma, headach, vertigo, hypochondriasis, &c. The signs of irritation may proceed from such a variety of organs that it ap- pears to be in a manner reflected from one to another. Thus irritation in the bowels is trans- mitted to the brain and spinal marrow, and from thence developes its effects on the voluntary muscles, producing spasms, convulsions, or cho- rea. If the original irritation persist long in this direction, it may become fixed on the nervous system, and there continue long after the irritating influence has been removed from the intestines ; the disorder of the nervous system may then be considered to be of the second kind of irritation, that, namely, of increased irritability. Calculus of the urinary organs frequently produces irrita- tion of a still more disturbing and unprofitable kind, which has worn down the feelings and functions of many a frame. Dentition is another fertile source of irritation in the bodies of sensitive children. As long as this is restricted to the pro- duction of a copious flow of saliva or a moderate diarrhoea, it can scarcely be said to be prejudicial; but it not unfrequently amounts to general dis- ordered secretion, wasting diarrhoea, and atrophy, convulsions, and paralysis; none of which effects tend in any intelligible way to promote the pro- gress of the tooth through the gum. Tumours in the brain or spinal marrow may excite epileptic convulsions, chorea, paralysis agitans, &c. Acci- dental productions, as tubercles, produce various signs of irritation, both local and sympathetic. Thus, in the lungs they occasion cough, in the bowels diarrhoea, &c, whilst their presence almost always irritates the heart and quickens the pulse. Foreign bodies or splinters of bone in the sub- stance of living structure frequently occasion severe irritation, with little or no decided inflam- mation. It may declare itself by pain and spasm in the part, and in the system by disorder of any of the functions, quickened pulse, hurried breath- ing, impaired digestion, delirium, convulsions, tetanus. Pus confined within the proper sheath of a tendon, under a fascia, or within any dense and unyielding tissue, may1 produce similar phe- nomena. 84 IRRITATION Such are examples of direct irritation, and many others might be adduced ; as the history of nume- rous diseases, medical and surgical, abounds in instances of the same kind ; but we do not pro- fess to enter into details, and enough has been said to illustrate the principle. Nor shall we do more than allude to another important and exten- sive cause of irritation, which we cannot hesitate to call direct,—inflammation. It is a cause not only sympathetically, or through the intervention of the nerves, but likewise by mere contiguity. Thus inflammation of the pulmonary pleura ex- cites irritation and consequent inflammation in the corresponding part of the costal pleura; and the same thing gives origin to the adhesions observed between the heart and pericardium, and the peri- toneum in its various points of contact. The phy- sical nature of this mode of the propagation of inflammation is involved in much obscurity; and although there are not sufficient grounds to iden- tify it with electric or galvanic action, it is ob- viously something beyond vascular or nervous communication. But through sympathy an organ or part affected with inflammation produces irri- tation in various other organs; this is fully exem- plified in what is called symptomatic fever, which can be referred to no other principle. It is, more- over, especially remarkable in the sympathetic re- lations which subsist between particular organs, as the mucous membrane of the stomach and bowels and the brain. And here, while we would acknow- ledge the truth and importance of the views of M. Broussais on these points, we would insist still on the propriety of distinguishing between inflam- mation and irritation. The secondary or sympa- thetic irritations may truly pass into inflammation ; but they more generally fall short of it, and there- fore require a different treatment; and it is a point important to be observed, that instead of being in proportion to the intensity of the primary inflam- mation, they are often most prevalent when this is very slight. Thus the cerebral and general ir- ritation accompanying well-marked gastritis is con- siderably less than that which gas-trie derange- ment, or what the French call •> embarras gas- trique," will produce. It would, perhaps, more nearly represent the reality if we say that the sympathetic disorder is in proportion rather to the irritation of the organ primarily affected than to the intensity of the inflammation. This predomi- nance of irritation over inflammation, although occasionally occurring in the robust, is a character more remarkable in individuals in whom the ner- vous system has the ascendency, whether by natu- ral constitution, or in consequence of the depres- sion of the vascular power by evacuations or inanition. It is thus that in delicate females vis- ceral inflammations are often accompanied by irritation and disorder quite disproportionate to their intensity or extent. Certain mental emotions are frequent causes of bodily irritation, and they act in a variety of ways. Anger, joy, and surprise, (which act as general stimulants on a healthy body, and if they tend to produce disease at all, it is congestion or inflammation,) when the bodily powers are in an enfeebled state, become direct irritants, and de- velop that partial and irregular excitement amoni by the word irritation. They exert their stint* lant relation almost exclusively on the nerve* system, which in this condition of the body ha already a disproportionate ascendency, and tlaas/ may thus greatly increase that loss of balance which is so much opposed to the state of health. Thus we see the necessity of excluding all suet influences from those whose functions are in that state of weakness or depression which continuili verges on derangement; such are convalescent! from fever and other severe diseases. Grief, fear, and anxiety are indirect irritants, and must there- fore be referred to the third head. 2. Irritation from Excessive Irritability, —We have already adduced examples of this kind in the case of the stomach after the evacui. tion of an emetic during pregnancy, or suppres- sion of urine, and under the influence of coneus- sion of the brain, and other injuries or shocks to the system. The intestines, when once excited by an irritant, sometimes present a continuance of irritation apparently from the same cause; and the irritability of the urinary bladder is known to bs morbidly exalted in the diseases of the adjoining parts. Inflammation is, however, the most com- mon cause of excessive irritability ; and it is io some measure a question whether the above ex- amples may not be referred to a stale more or less akin to it. But we see parts sometimes remain permanently irritable without any obvious increase of vascularity ; and as there is reason to suppose that sensibility is not always in proportion to the number and size of the vessels, it would not seen just to attribute the excessive irritability of an organ always to inflammation or even to conges- tion. Mr. Travers considers that the irritable joint, breast, testicle, and prostate gland, give no evidence of inflammation. He records instance of irritable breast and knee joint, attributed origi- nally to needles having entered the parts, whkh continued painful many months after the extrac- tion of the needles, in the total absence of inflam- mation. The facial nerves in those affected with tic douloureux present examples of excessive irri- tability ; a draught of cold air or the heat of a fire is enough to irritate them and the adjoining mus- cles into pain and spasm. The bronchial muscles are inordinately irritable in those subject to ner- vous asthma; and trifling causes, such as the effluvia of a stable, excite them to spasm. Othei idiosyncrasies might be quoted in proof of exces- sive irritability as a cause of irritation. After an irritation has been transmitted for a considerable length of time from one organ to another, the lit- ter sometimes adopts the habit, and continues to show signs of the same disorder after the original irritating cause has been removed. This is in- stanced in chorea, arising from feculent accumu- lations or disordered secretions in the intestinal canal. When these have been removed or re- stored to a healthy condition, the chorea some- times continues, and can only be removed Ij remedies directed to those parts of the nervous system in which the irritation has become fixed. The uterus in the irregular performance of its periodic function, is frequently the seat and fectf of irritation. The nervous excitement, or innerva- tion as Andral terms it, by which a flow of blood the functions and sensations which we understand j Is called to this organ at particular times, may M IRRITATION. 85 of its purpose, and instead of being relieved by the establishment of the catamenial discharge, displays its effects in the various forms of what is called hysteria. In this there may be or there may not be local plethora; if there be, the fault of relief must be in the secernent vessels of the uterus; but if there be not, the defect is probably in the sanguiferous system, so that they do not answer to the call. Each of these cases has its separate class of symptoms originating in irritation ; but as hysteria and other derangements of the uterine function are fully considered under their respective heads, we do no more than name them. Many other examples might be adduced to illustrate this mode of irritation; particularly in that numerous class in which a congestion or increased vascularity is the cause of excessive irri- tability ; but it is unnecessary to go further. It is by producing a state of this kind, that direct irri- tants may become causes of this second order of irritations. We may remark that many of the following class of irritations might perhaps be re- ferred to the same head. 3. Indirect Irritation, or the Irritation of Reaction. — In developing the principle of this mode of irritation, we have already cited many instances of its occurrence: these may be greatly multiplied, for they are as numerous as the sedative or prostrating agencies to which the animal frame is liable; but it will be sufficient if we notice generally the forms which they most commonly present. There is probably a succes- sive gradation of conditions from the slightest sign of partial reaction from the state of prostration, such as vomiting, rigor, and convulsion, up to a decided and violent reaction, bordering on inflam- mation and fever. All these we would designate as degrees of irritation dependent on the same physiological principle, and deriving the variety of their aspect from the number and force of the functions which take part in the reaction. We sometimes see it confined to a single organ ; thus the stomach shows it by vomiting, the diaphragm by hiccup, the brain by delirium ; whilst all other organs may remain in the state of prostration. Of this description is the effect of violent and exten- sive injuries or burns, and severe operations, in which the powers are almost overwhelmed by prostration, and the partial effort at reaction, in- stead of counteracting it, contributes to render it complete and fatal. The pulse here is quick and threadlike, the respiration short and suspirious, frequently with a general rhonchus throughout the chesty if there be no delirium, the intellectual and sensitive faculties are in a state of hebetude ap- proaching to stupor; the pupils are dilated, and the eyelids half closed ; the countenance pallid or livid; the surface and extremities cold ; the secretions, if not suppressed, are unnatural ; and the sphincters often fail in their office. All these are signs of direct prostration, and among them the irritation of reaction may declare itself in a solitary symptom, and in none more commonly than in vomiting, which is often indomitable to the last, and greatly hastens the fatal event. It seems to proceed from extreme irritability of the stomach, which rejects the blandest liquids. A low delirium, with various hallucinations of the perceptions, may equally accompany this state; it is a sign of the irritation of reaction in the brain, and is prejudicial both in being misplaced reaction, and by leading to bodily efforts which add to ex- haustion, and not uncommonly prove instantane- ously fatal. Convulsions arise in the same way, and produce similar effects. Such is exhaustion with the lowest signs of reaction. In other cases irritation takes a larger share in the diseased state consequent on the injuries under consideration. Thus, after rigors, the pulse may become sharp and bounding, with throbbing in the head; the eyes glassy, with contracted pupils; the delirium fierce, or there is great restlessness and morbid sensibility: spasms may occur in various parts of the body ; there may be pain in all degrees and positions; the heat may be partially increased, although the extremities are generally cold. Here, although beginning in prostration, the chief features of the disease are those of misdirected and exces- sive reaction. They border very closely on fever and inflammation ; and it would be rash to say that they are always distinct from these states: but although the delirium and exalted sensibility are sometimes so marked as to give suspicion of the existence of phrenitis, examination of the brain after death discovers no sign of increased vascular action further than some turgescence of the vessels, which is totally disproportionate to the intensity of the symptoms. Other organs, the lungs, the heart, the stomach and intestines, but particularly the serous membranes, are occasionally the seat of this kind of irritation, which puts on the semblance of inflammation; but less com-' monly in reaction after local injuries or operations, than after prostrating causes which have a more diffused seat in the system, such as cold, loss of blood, and inanition. The general tendency of all these irritations is to exhaust, and unless con- trolled and counteracted, they wear down and de- stroy the remaining irritability of the system, and death necessarily ensues. It is the continued impression of a sedative or prostrating influence that renders reaction imper- fect, and converts it into an injurious irritation. Thus the powers in general may be unable to rally after the first shock of any severe injury or operation; but this inability is frequently depend- ent on some additional sedative influence, bodily or mental. Fear and anxiety are most powerful in this way ; and instances are on record in which operations, trifling and favourable in their surgical relation, have led under their influence to a fatal result. Women have died after successful and natural parturition, barely from the effect of a pre- sentiment that they would die. To such instances cited in Mr. Travers' work before mentioned, he adds a case of the death of a lady after a labour protracted unusually by the evolution of a polypus after child-birth ; and another of a gentleman who died in twelve hours after the escape of the con- tents of the stomach by perforation into the peri- toneal cavity—ascribing these fatal events to the sudden, extreme, and unremitting pain: but we question whether they may not be as fairly attri- buted to exhaustion from muscular effort in the first case, and in the latter to the prostration of the heart's power by the severe and extensive in- jury to the peritoneum, as in other cases of acute peritonitis. Pain, though commonly at first a 8G IRRITATION. powerful irritant, when exceedingly severe occa- sions syncope, and by fatiguing the powers other- wise produces a prostrating effect: in this way it will tend powerfully to subdue the disposition to general reaction. It implies the worst species of mental excitement, which entirely prevents the repose essential to restorative reaction ; but as we sometimes see the body bear pain even in its great- est degree with impunity, and as we know that a certain integrity of the function is necessary for its continuance, we can scarcely look on it as being ever alone a sufficient cause for fatal prostration. The sedative influence of grief and fear is so decided that they may not only aid other causes, but by themselves destroy by prostration ; and this may, as in other cases, be with or without irritative reaction. But the most remarkable species of causes of irritative reaction are those which depend on in- anition, whether arising from bloodletting or other evacuation, or from imperfect nutrition. We owe to Dr. Marshall Hall the first distinct notice of these morbid affections: his observations have been confirmed by Dr. Abercrombie, Mr. Travers, Dr. Gooch, and other subsequent writers; and he has since given a fuller account of them in his " Researches on the Effects of Loss of Blood," a work recording some new facts of great practical importance. The immediate morbid effect of loss of blood, if extensive, is the same as that of the other pros- trating influences which we have mentioned, syn- cope, coma, convulsions, and delirium. The two latter, although they appear closely allied to the others, we cannot but view as different in their nature, and as resulting either from a partial effort of reaction, or from a remnant of local power, preponderating unduly over general prostration. They most frequently occur where the excessive loss of blood has been gradual, as by atonic hemor- rhage, epistaxis, by bloodlettings often repeated, or through a small orifice and in the recumbent pos- ture. The gradual draining of the system in these ways, or by other excessive evacuations, such as con- tinued purging, and by starvation, which have the same effect in the feeble, after the lapse of these symptoms frequently gives rise to a train of signs of irritative reaction of more prominent and de- cided form. There will be palpitation of the heart, with quick and jarring pulse, and throbbing of the carotids, aorta, and other arteries, and the auscultator will perceive a purring or grating sound in these parts. If this irritated state of the circulation continue, it will induce its effects on the sensations and functions ; sensibility will be increased, with intolerance of light and sound, pain, throbbing, and noises in the head, an excited state of the mind amounting to delirium, a loaded tongue, and general disorder of the secretory functions. This condition, which is amply de- scribed by Dr. M. Hall in the work before quoted, and in the articles Bloodletting and Absti- nence in these volumes, is a fair example of irri- tation in its characteristic form. Here is great excitement and disposition to act, but no power to regulate or support it: here are the nervous phe- nomena of inflammation without that permanent and powerful state of the vessels which can lead it to any of its usual terminations. The sem- blance of inflammation which it frequently pre- sents often induces the practitioner to draw mors blood • the evil consequences are sometimes j» mediate, syncope, convulsions, and death; i* when there is a temporary amelioration, it is onlj a prelude to a worse return of irritative reaction, So great is the real weakness in the midst of all the apparent signs of excitement, that the erect posture or any kind of exertion may prove falsi It may terminate fatally also in a more gradual way, by passing again into the state of sinking« pure prostration ; and here likewise it may put on a fallacious aspect in its resemblance to the sign of effusion on the brain. In children particular!?, this imitation is so close that Dr. M. Hall ha, called it the hydrencephaloid disease. In favour- able cases irritation terminates in subsidence and a gradual restoration of power, and with it a re- covery of balance among the functions. But the irritation may pass into a chronic state, and of this description Dr. Hall considers puerperal mania, amaurosis, deafness, paralysis, &c. The delirium, mania, and increased sensibility in those suffering from privation of food, recorded in several cases by Dr. Currie, Dr. Latham, An- dral, and others, are obviously of the same nature of irritations of reaction ; and in the pain of the head and stomach, and irritable state observed in those under the influence of a great and sudden lowering of diet, we see a more familiar illustra- tion of the same kind. Similar symptoms often accompany the wasted and atrophied condition of infants unduly nourished, with whom the mater- nal milk disagrees, or whose powers of digestion cannot master the food that is given them; and they not unfrequently develop themselves in the asthenia lactantium, and in any form of undue nu- trition. For further illustrations, see the articles Abstinence, Chlorosis, and Lactation (Dis- eases of.) Treatment of Irritation.—Having described irritation as a general pathological principle rathei than as a specific disease, our remarks on the re- medial measures calculated to counteract or remote it must be equally in the abstract, and merely. illustrated by prominent examples. The removal of the irritating influence, if pos- sible, is the most obvious indication in the cure of direct irritation ; and in the slighter cases this mij be a sufficient remedy. Thus, the removal of irri- tating matter from the stomach by means of an emetic; from the intestinal canal by a purgative; the counteraction of acidity by a dose of alkali, relieving by a stroke of the lancet the tension of the swollen gum in dentition, or of the integu- ments or a fascia in a superficial or deep-seated abscess, may amount to a complete cure of the various forms of irritation, which these causes se- verally occasion. But it is not always possible thus to reach the root of the evil; moreover, as we have already remarked, when once planted, the disease propagates itself so as in a degree to become independent of its first cause, and thua IB belong to the second class of irritations. Hence it often becomes necessary to combine, with the measures directed to remove the irritating influence, others calculated to diminish irritability; and where the original cause is obscure or bafiles our efforts, this is the only system of medication thai can be pursued. This combination is the more expedient in intestinal irritation, as the remedies IRRITATION, 87 «uited to remove the offending cause in themselves for a time aggravate the irritation. Thus it is proper in such cases to give before or with the purgative some narcotic, such as hyoscyamus or opium, and further, if necessary, to allay the irri- tation of its operation by diluents, the warm bath, and other derivants. It is not easy to lay down any rule by which the relative importance of these measures can be decided; but the sedative plan is generally more requisite in proportion to the length .of time and the degree in which the constitution has suffered under the irritating influence. Where the irritation is vehement, and disturbs in a serious degree the vital functions, it becomes of more im- portance immediately to allay this by temporising measures, than to rest solely on those which are more radical, but of slower operation. A child suf- fering from worms or accumulated freces may die of convulsions under the additional irritation of a purgative before its evacuant effect can be obtained; but if this medicine be preceded by or conjoined with others calculated to soothe, such as hyos- cyamus, Dover's powder, or the warm bath, accord- ing to the character of the irritation, its operation will be safe and seasonable. The purgative is, moreover, by the same means, often rendered more effectual for the removal of the irritating matter, since its slower progress enables it to act more generally on the canal, than where an excessive irritability hurries it precipitately through. So also, during the prevalence of violent spasm, an antispasmodic must often be promptly administered without regard to the duration of its effect. To give ether, laudanum, assafoetida, valerian, &c. in spasm of the glottis or bronchi, or in violent palpi- tation of the heart, may be, in relation to the cause f the irritation, a temporizing measure ; but it is using time to good purpose. We have enumerated inflammation among the causes of direct irritation, and we again allude to it for the purpose of remarking, that besides the removal of the cause itself, our attention may sometimes be usefully directed to the quieting of those nervous sympathies by which the irritation - is communicated to the system at large. This, we apprehend, is the principle of the salutary operu- "tion of opium in continued fevers and the less fcthenic forms of inflammation ; and did we possess a medicine that should be sedative to the nervous •system without exciting or disturbing the vascular, it would furnish a still happier and more satisfac- tory illustration. There are many cases in which the source of irritation is organic, or beyond the reach of reme- • dies; it is thus with tumours in the brain, spinal marrow, and oilier parts, accidental productions, cancer, and other forms of diseased structure; "-here our only resource is in measures which allay morbid irritability. We shall have occasion pre- sently to revert to this subject; but we see no need to dwell longer on means for the removal of irri- tating influences: they vary with the nature and locality of the influence. There is another mode of treating direct irrita- tions, which it may be convenient to notice in >connection with direct irritation, although it is more frequently applicable to the indirect kind, -namely, by stimulating applications. In enume- rating examples of direct irritation we named various mechanical injuries, and remarked that the object of irritation in these cases, the reparation of the injured part, is sometimes defeated, and the disorder prolonged in consequence of the low power in the vascular system, which is inadequate to take on the reparatory state of healthy inflam- mation. Here, then, an additional stimulus to the vessels, conjoined, if need be, with a sedative to the excited nerves, will often recall the irritation from its prejudicial wanderings through the sys- tem into a local and salutary channel. This treat- ment is obviously applicable only in cases where inflammation is not in itself a hurtful process, such as mechanical injuries and sores of the exterior, and especially burns and scalds. The efficacy of stimulating applications to the latter is now gene- rally admitted, and we would attribute it entirely to this principle in all the moderate examples of these lesions. The extreme heat has so paralyzed or weakened the vessels, that although they may be entire and congested with blood, they require a new and powerful stimulus to bring them to that activity of function which the reparation of the injury requires. When a part has been disorga- nized, and is insusceptible of revivification, and the adjoining vessels are weak and inactive, stimulant applications are still more obviously indicated to excite that inflammation which is necessary to effect the sloughing or separation of the noxious dead matter from the living structure. We can see the utility of a similar treatment in other forms of external disease, where the inflammation is at once irritative and powerless. We have already glanced at the treatment of our second order of irritations, that of excessive irritability, for the mixed manner of their occur- rence renders it inexpedient to consider each kind quite separately from the other ; but we return to the subject, in the endeavour, as far as is possible, to make this sketch of the principles of the treat- ment correspond with the preceding pathological history. Excessive irritability, as we have there remarked, most frequently depends on inflamma- tion or some of the states akin to it, or (to use the more comprehensive words of M. Andral) hyper- emia in its several forms. In such cases relief is to be sought in the various antiphlogistic measures, applied of course with due relation to the organ whose morbid irritability is to be reduced ; and thus evacuants, derivants, counter-irritants, and coritro-stitnulants, become remedies for irritation. These are considered in the article Inflammation sufficiently to supersede notice here, further than the remark that their anti-irritant may not always be in the ratio of their antiphlogistic effects; and where irritation predominates over inflammation, those are to be preferred which act on the nervous as well as on the vascular functions ; thus, counter- irritants (and if they be admitted as a separate class, contro-3timulants also,) will avail more than mere vascular depletories in fulfilling the indication in view. For example, in the vehement irritations connected with slight phlogoses of the mucous membrane of the lungs and of the alimentary canal, (notwithstanding Broussais' positive asser- tions to the contrary,) tartar-emetic frictions for the former, and sinapisms and blisters for the latter, are far more efficacious than local or general blood- letting. The irritations of serous membranes, IRRITATION. which in persons of mobile sensibility frequently present the semblance, although they partake little of the real character, of inflammation, likewise receive most relief from this description of anti- phlogistic treatment. The contro-stimulant or sedative influence of cold directly applied is ex- erted equally on the vessels and nerves, and it would be, doubtless, a powerful means of subduing irritations, were it a more manageable agent; as it is, we see its beneficial influence in the relief afforded to cerebral irritation, and in those of the limbs by applications of ice and cooling lotions. The expediency of using it, (as do the Broussaians) in abdominal and thoracic inflammatory irritations, is very questionable: the risks of repelling the inflammation more inwardly, and of its being ag- gravated by reaction if the application of cold is unsteady or insufficient, besides the obvious injury to the system of continually abstracting from or- gans that degree of heat which is almost neces- sary to their life, are surely sufficient objections against a practice that is far from being generally recommended by the experience of its advocates. External heat, whether dry, as applied by hot flasks, bricks, or air, and acting as a rubefacient, or combined with moisture in fomentations, baths, or poultices, and proving revulsive and sudorific, is a much less exceptionable remedy for internal irritations. In its moderate degrees the latter are more suited to inflammations, as their effect is principally on the circulation, which they soothe and equalize; but in its highest tolerable degree, heat produces a strong impression on the nervous system; very hot flasks, or flannel wrung out of water almost scalding, are among the most power- ful of antispasmodics or local anodynes, and we have seen them produce perfect and immediate relief in the irritative pains of colic and dysme- norrhea, where many powerful narcotics had failed. As we are now verging on the subject of means directed particularly to lower nervous irritability, we may premise that there are some narcotic or sedative remedies which, if they do not act as such on the vascular system likewise, do not stim- ulate it; they are, therefore, often admissible in inflammation itself, and are the more strongly in- dicated when it exhibits the character of nervous irritation. Of these, none for safeness and general applicability ranks before the hyoscyamus. Mr. Travers says, " In the ruffled states of the system generally, but especially in the over-active state of the vascular system, there is a charm in the operation of henbane altogether peculiar. It is feeble as an anodyne, feebler as a soporific, but ' not poppy nor mandragora' soothe and still so unexceptionably as henbane." This remark, al- though true, requires a comment; the over-activity of the vascular system here alluded to is not one of inflammation, but of irritation, dependent on excess of nervous irritability scattered through the different organic sympathies; and it is in its sedative influence on these that the charm of hen- bane consists ; for it exerts little or no effect on inflamed vessels, that are, as it were, over-active in their own strength. We may almost say that on its little interference with the vascular system its general eligibility depends; for, restraining no secretions, it can advantageously be given alone or combined, without the risk of purchasing tem- porary relief at the expense of that balance of functions which is so essential to health; age] unless where pain and excited sympathies « useful as guides in the employment of more active remedies, there is scarcely an instance of morbid irritation unfitted for its use. The main fault of hvoscyamus is its weakness as a narcotic; it not unfrequently fails of its effect, and, perhaps sooner than other remedies of the same class, loses id power by continued use. Of the other remedies of this class we maj mention favourably conium, belladonna, colchi- cum, digitalis, and hydrocyanic acid. Their fitness in various diseases is less extended than that of the medicine already named ; and it is particularly restrained by their greater liability to disagree with the stomach. The two first approach in theii properties most nearly to hyoscyamus. The three others exert a decidedly sedative effect on the vas- cular system, but rather through an influence on the heart, the force and number of whose pulsa- tions they diminish, than from any action on the vessels at large. Their beneficial effect is, there- fore, best seen in irritations of this organ and of the lungs, which stand in so close a relation to the heart. The directly sedative influence of hy- drocyanic acid is, however, sometimes remarkably evinced by its allaying the morbid irritability of the stomach; and it is successfully applied exter- nally to allay the irritation of prurient eruptions. Colchicum is supposed to possess a specific seda- tive power in the irritations of gout and rheuma- tism. Whether this may depend on its carrying off through the kidneys an irritant matter from the blood is uncertain; but the diuretic effect of this remedy and of digitalis should not be over- looked. Conium and belladonna, when the sys- tem can bear them in sufficient doses, are some- times very beneficial in allaj'ing irritation of the pulmonary system, whether manifesting itself in spasm of the bronchi, or in an excessive irritability of the mucous membrane, exciting cough. The smoke of stramonium and of tobacco enjoys I similar reputation, but it is decidedly stimulant to the vascular system. Poultices of the recent leaves of various narcotic herbs, but particularly conium and belladonna, are very efficient in allay- ing the irritation of unhealthy ulcers: the leaves of the latter in form of ointment show great power over both vessels and nerves, in relieving and pre- venting the chordees of gonorrhoea. We pass over others of lesser note to the chief of narcotics, opium. This medicine, although under certain circumstances the most sure and most powerful of anti-irritants, has so many ulte- rior effects, that more than any other it requires judgment in its exhibition. Its first effect is to stimulate the vascular system, and this is sufficient to exclude it from all those instances of sthenic inflammation where it is wished to retard or arrest rather than to hasten this process. But in the asthenic phlegmasia;, especially where nervous irritation predominates, the administration of opium is counter-indicated only by the ulterior effects which it may have in arresting the secre- tions. Combined with ipecacuanha, with anti- mony, and especially with mercury, it ceases to be liable to this objection, and its operation is often in the highest degree salutary. Even where IRRITATION. 69 it is wanted as a pure anti-irritant, to reduce mor- bid sensibility in the nerves, we should always prefer it in combination with ipecacuanha, which seems to equalize without injuring its narcotic virtues; and in further combinations, it is not common to experience from this compound the inconveniences that frequently result from lauda- num or opium. The muriate and acetate of mor- phia, equally with Battley's liquor opii sedalivus, enjoy the reputation of a purer sedative property than the common forms of the drug possess; but unless where a speedy effect is desired, there are few cases in which we would not place greater confidence in Dover's powder, or tantamount combinations of ipecacuanha and the aqueous ex- tract of opium. It is an almost indispensable adjunct to purgatives in violent gastro-enteric irritation where hyoscyamus would be insufficient; and if the stomach will retain it, it seldom fails to quell the excessive disturbance that sometimes follows drastic and unguarded purgation. In dysentery, and in more chronic forms of excessive irritability of the intestinal canal, the proportion of ipecacuanha may with advantage be doubled or quadrupled, as in the dose of one-fourth or one- eighth of a grain of extract of opium, with one- half or a whole grain of ipecacuanha, repeated according to the urgency of the symptoms. We must notice a more obscure class of reme- dies, alteratives, which, whatever may be their mode of action, are unquestionably entitled to a place here. Under this unscientific but convenient title, we reckon the various non-purgative forms of mercury, whether simple or combined with opium, those of antimony and ipecacuanha in acute dis- eases, and in chronic disorders minuter doses of the same, sarsaparilla, mezereon, chalybeates, and a host of other medicines. The efficacy of the first-named of these in restraining and subduing inflammatory action would obtain for them, among the disciples of the new Italian doctrine, the ap- pellation of contro-stimuli; but this, like cutting the Gordian knot, is only substituting a bold stroke of hypothesis for a solution of the difficulty. It is not impossible that tartar-emetic and mercury may exert on the coats of inflamed or irritated ves- sels such an influence as directly neutralizes or subdues their disorder, and restores their healthy function ; but this is a large assumption to take for granted ; and in the absence of any sort of positive proof, we think it safer and as philosophi- cal to arrange the remedies in question under the modest title of alteratives. These remedies are powerful in subduing irritation ; and on the basis of the views which we have given of this morbid state, we might equally well frame an hypothesis that they act by restoring a lost balance, and by equalizing the distribution of natural irritability. But we will content ourselves with remarking the fact, that mercury, antimony, and in a minor de- gree ipecacuanha, tend moderately and equally to restore all the secretions which inflammation and irritation arrest or pervert; whilst opium, deprived in this combination of its restringent qualities, happily allays the excited sensibilities and sympa- thies of the nervous system. The alteratives pre- scribed in chronic irritations, although in greater variety, probnbly net on the same principle; and, perhaps, the exhibition of what are called altera- Vol. III.—12 H* tive doses of blue-pill, Plummer's pill, ipecacu- anha, dandelion, and sarsaparilla, and mineral j waters in chronic diseases of the viscera and skin, is more generally acknowledged as an appeal to the various secretions. Before passing to the last class of remedies, tonics, we would advert for a moment to the salu- tary effect of friction and exercise in allaying morbid irritabilities of a part of the system. They hold an intermediate place between-alteratives arid tonics, and in affinity with either they well merit consideration. Friction, steadily and moderately applied, is an efficient anodyne. Although inju- rious in acute inflammations, it allays in a won- derful manner various nervous pains, spasms, and other disagreeable sensations connected with irri- tation and irregular circulation, and it is a valuable auxiliary to anodyne applications. It is an alter- ative to the vascular system, inasmuch as it re- moves congestions and obstructions, and promotes healthy circulation and secretion ; and in the regular continuance of these effects by exercise, increased by the contact of pure air, consists the tonic power of these hygeian agents. The utility of tonics in subduing morbid irrita bilities will, if we mistake not, be sufficiently apparent from the pathological views which we have endeavoured to expose. Agents which give tone and strength to the vascular system will de- stroy the preponderance of that nervous mobility which is the basis of irritation. Under their prosperous influence, disposition and power to act will go together, and within due bounds produce the harmonious balance of even health. Whether certain of them possess a specifically sedative pro- perty towards the nervous system, or whether this is their secondary effect after their tonic and as- tringent influence on the vessels, is beyond our means of decision ; but the fact is not less ascer- tained than important, that the continued use of nitrate of silver or sulphate of copper will cure the epileptic irritations independent of organic cause, and often diminish them where the cause is irremovable, by lowering in the nerves their susceptibility to its impressions. Thus, likewise, bark, carbonate of iron, arsenic, sulphate of zinc, or subnitrate of bismuth, sometimes remove the painful or spasmodic irritations of tic douloureux, hemicrania, sciatica, chorea, and gastrodynia, which the most powerful anodynes, antispasmo- dics, and counter-irritants fail to effect. The stomach and intestinal canal, likewise, under the influence of a bitter tonic, will often lose various signs of irritation, which, however they may occa- sionally be accompanied by slight hyperemia, or fancied inflammations, owe their being to weak- ness and want of tone. The cold shower or plunge-bath, or cold ablution, is another efficacious tonic; the more eligible, often, because, without loading the system with medicine, it rouses it to the exertion of its own powers in a vigorous vas- cular reaction, under the habit of which nervous mobility is physically forgotten, and ceases. But it is needless to add to examples which have been adduced only as illustrations of a principle. We have, finally, to glance at the leading pecu- liarities required in the treatment of indirect irri- tation, or that arising in the reaction after prostra tion. The most obvious indication is to promote 90 IRRITATION. and regulate the reaction, so that it may rise to the point of a general and equal recovery of func- tion, without passing beyond it into a state of irritation or inflammation. The most common skin, like other parts, seems to have lost the attri- butes of vitality. Of the diffusible stimuli fit to oppose the state of sinking or prostration, the most powerful are state which we have to deal with is that of irregu- ammonia, alcohol, and opium. These are variously lur reaction, local and misdirected excitement I applicable, according to the degree to wfticn the amidst general prostration. Whether this excite- depression has extended. Ammonia is the most ment consist in convulsion, hiccup, vomiting, de- • purely stimulant, and is, therefore, best adapted to lirium, palpitation or cough, it is of the utmost ' cases in which there is least ot local irritation, or importance that it should be subdued; and to effect where this manifests itself in spasms. The com- this, it is of more avail to direct our efforts to ex- | plete prostration induced by tobacco, digitalis, and cite the powers generally, by diffusible stimuli, ; other sedative poisons, and the asphyxia from the than to attempt to quiet the local irritation by j fumes of charcoal and sewers, are examples to sedatives; for as the other powers rise from the which the stimulus of ammonia seems to be espe. prostration, this symptom will generally subside. I daily adapted. The carbonate of ammonia is the But should this not be the case, and the local irri- \ most common preparation, and it is conveniently tation be wearing down the strength, sedatives combined with alcohol in the spiritus ammonias must be addressed to it: this part of the treatment ! aromaticus, which is the form most agreeable to will not differ from that of morbid irritability | the stomach. It is to be borne in mind, however, already considered. The point which character- , that it is a chemical agent as well as a vital izes the treatment of this form of disease is the stimulant; and this circumstance precludes its necessity for counteracting the prostrating influ- | being given to a very large amount. Spirits in ence which paralyzes the plurality of the functions, ! the various combinations, brandy, wine, and ether, leaving others in proportionate predominance. This indication resolves itself into the removal, as far as is possible, of this influence, and the further obviatiou of its effects. Cold, and the resulting prostration, are removed is a highly valuable stimulant; and it is the one perhaps most to be depended on in general pros- tration with irregular reaction. It exhibits some narcotic virtue in its property of quieting the irritated sympathies of this state, and is peculiarly by the same means, the gradual and cautious serviceable in arresting the severe vomiting which restoration of heat, beginning by frictions with often severely and fatally aggravates various formi snow, &c. and carefully restraining the disposition j of exhaustion. It is of the greatest importance to which is commonly manifested to excessive reac- i watch most assiduously the state of a patient who tion ; on this account diffusible stimuli are only : requires a large exhibition of stimuli of this kind, sparingly admissible. See Cold. both to ensure their being supplied often enough, The prostrating influence of a severe me- which in case of sinking must be done every five chanical injury, as of a crushed limb or bad com- | or ten minutes, and to diminish or withdraw them pound fracture, seldom ceases on the removal of ! the moment they produce an effect on the circu- the limb ; on the contrary, the additional shock lation, lest they stimulate it beyond the point of of the operation not unfrequently proves fatal, moderate and general reaction into a state of febrile The absence of inflammation leaves the system excitement. Opium, as it partakes largely of nar- open to the noxious influence of the shattered cotic as well as of stimulant properties, is less structure, which inflicts a stroke felt even after its adapted to the extremest forms of prostration than removal. Were healthy inflammation soon ex- to those in which the irritability of the system it cited, this would probably in a degree counteract, misdirected. In the state of sinking, when the or interrupt this influence ; and we hazard the respiratory function is failing with the rest, opium suggestion that stimulating applications made to might have the etfect of destroying the sensibilities the injured part previously to the operation, might, and sympathies on which this vital process depends. as in extensive burns, be of more avail than mere ' But for the different partial irritations attendant on internal stimuli. The existence of inflammation general weakness, particularly dehrium, spasm. in the system has been shown by Dr. M. Hall to protect it in a remarkable degree against the pros- trating effects of loss of blood, and the same thing obtains in some measure in other cases of prostra- palpitation, and hiccup, opium is generally the most satisfactory remedy. Solid opium and its tincture are here the most expedient forms; and their stimulant eifect is most fully developed tion; hence asthenic inflammation may be useful j by small doses frequently repeated If the and not only as proving power in the system, but also j spasmodic property ,s desired, larger quantities as a general tonic, imparting a stimulus to the , must be given; and it is truly astonishing what heart and vessels. This remark is most applicable , doses the system will bear when under the intiu to surgical cases, in which inflammation is an im- ence of spasmodic disease portant and necessary process; but we see in it | The first objects in extreme prostration are, to also an explanation of the utility of artificial in- | sustain the functions of respiration and circula- nammations excited by sinapisms, blisters, and tion by diffusible stimuli, until there is a sufficient stimulant frictions in failure of the powers from , recovery „f the forces to support these without various causes, and in the state of sinking from further aid. The organic functions of secretion any severe disease. Any of these measures, as and assimilation the,, generally require some local counter-irritants and general stimulants, , assistance; for the effects of the depress ng influ- often prove beneficial in arresting vomiting, hie- j ence sometimes manifest themselves on them after cup convulsions, or any other partial reaction, the circulation has been restored to some deeree amidst general prostration. In the worst cases, of vigour. Here alteratives and tonics comeln o however, they fail to excite inflammation; for the , requisition; and, as in direct irritation they ml IRRITATION —JAUNDICE. 91 be variously modified and combined, in order to ensure the most equal and natural excitement of the several organic processes. Where the pros- trating influence still remains in the system, coun- teracting vigorous reaction, and enfeebling or para- lyzing all the conservative powers, these several remedies must be conjoined. Thus, under the noxious influence of gangrene, asthenic erysipelas, or poisoned wounds, it becomes necessary to ad- minister wine or spirits, ammonia, opium, or cam- phor, with bark or sulphate of quinine, whilst the secretions are excited by calomel or blue pill. Bark has sometimes a signal power in combating with the depressing influences in question; and its efficacy may, perhaps, depend on the same pro- perty which renders it so complete an antidote to the causes of intermittent fevers. The irritation of inanition, in respect to its symptoms, may require in great part the same treatment as that from other causes ; thus seda- tives to the nervous system, and the exclusion of all sensorial excitements, will be equally necessary. But the nature of the causes may modify the in- dications: as they consist in a loss from the sys- tem, the necessity of supplying nourishment for the reparation of that loss, giving to the assimila- tory organs the aid of additional stimuli, is obvious. It is necessary to be on our guard against the invitations which these forms of disease sometimes hold out for the use of antiphlogistic measures: these afford but temporary relief to the pseudo- inflammations which arise in this state, and which are more safely and effectually subdued by seda- tives, a judicious supply of nourishment, and an exclusion of all exciting or disturbing agencies. Thus we may see a disease following extensive evacuations, which puts on the semblance of vio- lent pleurisy, pericarditis, arachnitis, or hydroce- phalus, often completely relieved by hyoscyamus or opium, with a sustaining nourishment, such as sago, arrow-root, or jelly, with small quantities of brandy or wine. The state of the circulation is the safest guide in the conduct of this treatment; as long as the pulse is weak or fluttering, with its quickness, and although sharp or jarring in its first impulse, yet leaves the artery in the intervals empty under the finger, the sustaining treatment must be continued, and local pains, palpitation, disturbance of the mind with beating.or noises in the head, viewed as partial reactions, to be sub- dued by opium or hyoscyamus rather than by the lancet and evacuants. But if these symptoms have been relieved, and the pulse has recovered in a measure its steadiness and fulness, the spirits and other stimuli must be diminished or with- drawn, and the rest of the cure left to time and to whatever alteratives circumstances may suggest. These points are more fully described under the heads of the several diseases connected with this subject, and which have been already referred to. The prophylactic treatment of those liable to irritations will generally consist of those means which, by giving tone to the vascular system, re- move the preponderance of nervous influence or susceptibility. These are tonic medicines and a tonic regimen in general; but if there be already a loss of balance in the vascular system, it will be generally necessary to direct some alterative to regulate it. There are various circumstances of diet and regimen which tend greatly to engender a general morbid irritability; particularly an habitual and excessive indulgence in spirituous liquors, smoking, very strong tea or coffee, and opium-eating; close or crowded habitations, and a sedentary mode of life. Besides avoiding these predisposing causes, those who are of an irritable habit should rise early, and keep regular hours, use exercise in a bracing air freely, but not so as to induce much fatigue, live on food of the most wholesome and nutritious kind, and attend in every possible way to the promotion of equality and regularity of the functions. C. J. B. Williams. ISTHMITIS. (See Thro at, Diseases of the.) ITCH. (See Scabies.) JAUNDICE. ("iKTtpos, icterus, morbusregius, aurigo, SfC.) Jaundice is a disease of rather fre- quent occurrence, characterized by a yellow colour of the eyes, skin, and urine, and by the white appearance of the alvine evacuations. In addi- tion to these general symptoms, the malady is frequently attended with extreme depression of spirits, languor, inactivity, and watchfulness; with a bitter taste in the mouth, thirst, loss of appetite, nausea, or vomiting; a sense of fulness or other uneasiness, if not also actual pain, at the epigastrium; occasional shiverings and profuse perspirations; a distressing degree of itching in the skin, and rapid emaciation. The urine soon becomes of a deep mahogany colour, yet gives a bright yellow tinge to substances immersed in it. The state of the bowels is variable, being in some cases relaxed, in other cases confined, but gene- rally acted upon with facility by mild aperients. [Dr. Mackintosh (Principles of Pathology and Practice of Physic, 2d Amer. edit. i. 431, Philad. 1837,) states, that he has known several indivi- duals affected with jaundice, who saw every ob- ject coloured. Most of the secretions are unques- tionably tinged yellow, but not all. The colouring matter of the bile is rarely found in mucus or milk, for example. Yellowness of the conjunc- tiva is, however, one of the pathognomonic phe- nomena. Bile is, also, necessarily present in the blood-vessels of the retina ; yet, as the writer has elsewhere said, (Practice of Medicine, 2d edit. i. 625; Philad. 1844,) yellow vision is not common. In the experience of one observer, Dr. J. P. Frank, it was noticed but five times in about 1000 cases. Much difference of opinion has existed in regard to the cause of the phenomenon when it does exist. The most probable supposition is, that the hu- mours themselves are tinged yellow, and it has been suggested, that where vision is not yellow, they may have escaped the tinge. There is some plausibility, however, in the supposition, that tho cause may be wholly nervous, inasmue/h as pa tients, in other diseases, as in typhus fever, with- out being in the slightest degree jaundiced, have seen every thing yellow. It is possible that dif- | ferent conditions may be occasionally concerned in the causation.] | The circumstances which predispose the sys- tem to an attack of jaundice are numerous. The ! melancholic or leucophlogmatic temperament, under mental excitement, whether of a pleasant or painful nature; an indolent mode of life, | sedentary occupations, a full and stimulating diet, 92 JAUNDICE and habitual constipation, are among the most powerful. The occasional or exciting causes of the dis- ease are chiefly such as either suddenly stimulate the liver to an increased secretion of bile, or ob- struct the free egress of that fluid. Thus, a heated almosphere, strong muscular exertions, sudden and powerful emotions of mind, spirituous or other fermented potations, a large and indiges- tible meal, faeces impacted in the transverse colon, pressure from a gravid uterus, may induce an at- tack of jaundice. The proximate cause or essential nature of the disease evidently consists in an obstruction to the passage of bile in its course from the liver or gall- bladder to the duodenum, in consequence of which it either retrogrades into the blood-vessels of the liver, or is absorbed from the surfaces of the biliary duce either general or local inconvenience. Ool of nineteen instances of biliary calculi, which oc curred to Morgagni, besides four to Valsalva, i, post-mortem examinations, not one had expe- rienced jaundice. Yet a general failure of health has been observed, wbere, after death, no morbid appearance could be discovered except that of calculi in the gall-bladder. (Abercrombie on the Diseases of the Abdominal Viscera, p. 370.) Dr. Heberden remarks that, «in nearly twenty per- sons, a supposed pain of the stomach, which had frequently afflicted them for months or years, wai at length joined by a jaundice." (Transactions of the College of Physicians, vol. vii. p. 171.) In those, cases, it is probable that the occasional pain arose from some change in the position of the calculi in the gall-bladder. That they do not always remain in the bile-receptacle with impu- ducts. There are many morbid conditions of the j nity is clearly proved by the testimony of morbid liver and its appendages, as well as of the adja cent organs, which may induce such an impedi- ment. Not a few of these have been ascertained by the most conclusive evidence. Others, origi- nally devised by the fertile imaginations of noso- logists, and considered as adequate to the produc- tion of jaundice, have been successively handed down from author to author, not as merely proba- ble causes, but as legitimate deductions from established facts. Instead, however, of specify- ing the greatest number of morbid conditions anatomists. Soemmering repeatedly found the mucous lining of the gall-bladder in a slate of ulceration, occasioned by the irritation of the con- tained calculi ; while other pathologists have ob- served a general thickening of its coats, and dis- organization of its whole texture. The number of calculi sometimes contained in the gall-bladder is almost incredible. Morgagni took out of one body 3646 ; and in the Hunterian museum at Glasgow, 1000 are preserved which are stated to have been extracted from one gall- which may possibly give rise to jaundice, we shall ', bladder. The form and size of these calculi are very various. In a few instances they have nearly taken the shape and attained the magnitude of the gall-bladder itself, but generally, are from an eighth to a one-half of an inch in diameter, and of a polygonal form. (See Mr. Brayne's very interesting cases in the Medico-Chir. Trans, vol xii.) The broken or divided portions of the larger calculi have sometimes corresponding con- vexities and concavities, proving that they were once united. And it is not improbable that the smaller calculi are often subdivisions of a larger mass, formed into distinct calculi before consolida- tion was completed. The sides of these calculi are often flattened as if from close contact and endeavour to comprise, under a few leading divi sions, those phenomena alone which pathology has clearly ascertained. Such, we think, may be conveniently arranged under four general heads. 1. Obstructions arising from biliary concretions or other altered conditions of the bile, as well as from worms, hydatids, or other foreign bodies. 2. Obstructions arising from diseased states of the liver, gall-bladder, or biliary ducts. 3. Obstructions arising from morbid conditions of the duodenum. 4. Obstructions produced by the pressure of enlarged contiguous viscera. I. The first class of obstructions—those aris- ing from Biliary Concretions or other al- tered Conditions of the Bile itself— have received an almost disproportionate share of atten- tion from medical writers. The learned Heber- den, for example, scarcely seemed to recognise any other causes of jaundice. There can be little pressure. The chemical and physical characters of biliary calculi have been already described in this work under the general title of Calcclis. In that condensed but highly-interesting article the dis- tinguished author has given a very perspicuous doubt that a highly inspissated state of the bile I account of the more frequent forms of biliary may alone produce temporary jaundice. In some ! calculi; but may not have thought it necessary to instances, after great depression of mind and tor- ' allude to one or two kinds of uncommon occur- por of bowels, the stools become white, and the rence, which yet, we conceive, may prove of some skin of a dusky-yellow colour. Under the opera- importance in a pathological point of view. We, tion of a brisk mercurial purgative, the patient : therefore, make no apology for introducing them voids a quantity of dark, pitchy, viscid matter, of I in this place. sufficient tenacity to be drawn out in threads. | The first of these, as we are informed by Pro- He becomes immediately relieved, the skin and I fessor Turner, was discovered by M. Bizio, of the alvine dejections gradually resuming their I Venice, in a peculiar fluid, quite different from natural colour. Such cases we may warrantably refer to a thickened and vitiated state of the bile, which, in other instances, has been found of the same pitchy tenacious character while contained in the gall-bladder itself. Biliary calculi unquestionably form a very fre- quent cause of jaundice. Their mere presence bile, which was found in the gall-bladder of a person who had died of jaundice. It is of a green colour, transparent, tasteless, and of the odour of putrid fish. It is unctuous to the touch, may be scratched or cut with facility, and has a specific gravity of 1-57. M. Bizio has given it the name of erythrogm. (Dr. Turner's Ele- in the gall-bladder does not usually seem to pro-1 ments of Chemistry, p. 65C.) JAU-NDICE. 93 Another remarkable kind of biliary concretion is described by Dr. Marcet, in the following words. « Within the last few days, I have seen and ana- lyzed a large biliary calculus entirely different in its chemical composition from the above descrip- tion, and, as far as I know, presenting a new fact in the history of these bodies. This concretion contained no adipocire (cholesterine), and con- sisted wholly of carbonate of lime tinged by bile. It was of a bright yellow colour. It was heavier than water, and measured two inches five-eighths in length, and two inches and a quarter in its largest circumference." (Marcet on Calculous Diseases, p. 151, note.) This extraordinary pro- duction was found in the gall-bladder of a dead body by Mr. Green, (now Professor Green,) de- monstrator of anatomy in St. Thomas's Hospital. The formation of biliary calculi is still in- volved in much obscurity. Many of the circum- stances before enumerated as predisposing to jaundice generally, are found peculiarly to favour the formation of calculous concretion. Such are depressing emotions, deficient bodily exercise, a full diet and frequent constipation. Had biliary concretions been always found to consist merely of inspissated bile, there would have been no dif- ficulty in conceiving how the want of exercise and similar causes, by favouring the retention of bile and the gradual absorption of its thinner parts, should ultimately lead to an actual concre- tion of the residual mass. And that this has sometimes occurred is sufficiently proved. Van Swieten, in his Commentaries, relates the case of a boy whose gall-bladder contained eight pounds of a thick sort of bile, consisting of a number of concentric strata, each stratum becoming firmer as it approached the circumference. There had, however, been no jaundice, although the stools were of a white colour. Biliary concretions, however, very rarely consist of bile alone ; and even where an admixture of bile or a distinct stratum of bile does exist, the central portion is generally of a very different nature. Something more, therefore, than consolidation must take place. Either the original secretion of bile must be faulty, or, in consequence of long retention in the gall-bladder, it must undergo some changes by which its constituent parts become disunited or converted into new products. Probably these different states of bile occur in different cases; inasmuch as calculi are sometimes found in the liver itself, and inasmuch, too, as some kinds of calculi approach nearly to the known constituent principles of the bile, whereas others exhibit cha- racters of a very dissimilar kind. May not also the mucous secretion of the gall-bladder become so altered in its nature, in consequence of the long retention of vitiated bile, as itself to furnish nuclei around which the dissociated constituents of the bile, or new formations from it, arrange j themselves? The peculiar nature of some of the nuclei, as well as the effect of long-restrained secretions on other mucous surfaces, afford some countenance to this idea ; although it must be admitted that the gall-bladder, from the adaptation of its structure to its peculiar function as a recep- tacle, is less likely to suffer from the detention of its contents than other mucous tissues exposed to the long-continued contact of their secretions. An inquiry into the power by which biliary cal- culi are propelled forward necessarily involves some interesting points connected with tRe struc- ture of the gall-bladder and the biliary ducts, which would lead us into a discussion somewhat foreign to the practical object of this paper. We shall merely remark that the effort of vomiting, whether spontaneous or otherwise, has probably a considerable influence in the extrusion of these concretions. Dr. Pemberton, indeed, does not ascribe any such effect to vomiting, unless where a calculus, from its peculiar size and form, entirely blocks up the duct, and obliges the bile to accu- mulate behind it, thus forming a kind of wedge which thrusts it further forward. To us, on the contrary, the impulse given in the act of vomiting would promise to be more effectual if the calculus did not very firmly or entirely close up the duct, but rather permitted the fluid bile, when strongly impelled, to slip along its sides; in which case, if the quantity of bile were too considerable to pass off quickly by the portion of the duct anterior to the calculus, it must necessarily swell it out, and thus prepare a way for the freer egress of the de- scending concretion. We are not aware that any examples are re- corded of very large calculi having passed through the biliary ducts; yet there is ample proof of the great distensibility of these passages. Dr. Baillie has seen both the ductus hepaticus and the ductus choledochus enlarged to the diameter of half an inch. When such a degree of distension takes place, there is generally a proportional thickening ; in truth, an actual growth in every direction. Most commonly, however, if not always, when concretions much exceed the diameter just men- tioned, they are expelled from the system by a different process ; an adhesion is formed between the gall-bladder and the duodenum, and a suffi- cient opening effected by ulceration. The calcu- lus thus brought into the duodenum is either then propelled along the intestinal tube and evacuated by the bowels, or a further adhesion takes place between the duodenum and the abdominal pa- rietes ; an abscess is formed ; ulceration proceeds ; and, at length, the irritating substance is protruded through the opening in the integuments. The cases related by Mr. Brayne, to which we have before adverted, afford beautiful and striking illustrations of the former and more perfect mode of extrusion. The patients, in at least two in- stances, recovered. Of the latter mode of expul- sion, to wit, that by an external opening, many examples are recorded, from which we may adduce one as related by the venerable Heberden. The patient, after having suffered for years from a dis- charging tumour near the umbilicus, was seized with acute pain, nausea, and vomiting, " et post paucos dies exiit calculus fellis tres pollices lon- gus, totidemque ambitu, quique pendebat grana ccxlv." (Commentarii de Morborum Histoiia, &c. p. 213.) Jaundice may be presumed to arise from biliary calculi, or other similarly acting obstructions, when its accession is sudden and accompanied by acute pain either in the epigastrium, or shooting towards that part from the back or right hypo- chondrium ; especially if there be also vomiting and occasional shiverings, or profuse perspirations, 94 JAUNDFCE without any manifest fever or an increased force or frequency in the pulse. Not uncommonly, the pain precedes the appearance of jaundice, return- ing, perhaps, with great severity for several suc- cessive days, and remaining for several hours at each return. Unlike the rigors which forebode an attack of inflammation, the shiverings in jaun- dice rarely precede the pain, but occur irregularly during a paroxysm, and seem to mark a further propulsion of the calculus along the irritated ca- nal, or its final extrusion through the distended opening of the common duct into the duodenum; The character of the pain is very important: it is acute, and occurs in paroxysms. Sometimes it is intense and excruciating in the highest degree, far exceeding what is felt in the most acute inflam- mation. The perspiration which sometimes drops from the patient may be ascribed chiefly to the severity of his suffering. The position of the pa- tient also deserves attention. He bends the body forward upon his knees, when not writhing in other directions, and seems to find some relief from pressing upon the seat of pain. Not unfiequently the pain subsides on the appearance of jaundice. The state of the pulse will materially assist in the diagnosis. During the state of simple irritation it is seldom much accelerated or preternaturally firm. When, indeed, it becomes materially harder and quicker, the utmost vigilance should be exercised lest irritation should proceed to inflammation ; in which case, the pain usually becomes more con- stant, the tongue whiter, and vomiting more inces- sant. These symptoms sometimes rise to such a degree as to resemble those of the ileus, to which, indeed, they then become nearly allied. It may be proper here to intimate that the entire subsidence of the pain, vomiting, and other charac- teristic symptoms, does not necessarily imply the passage of the calculus into the duodenum. Very frequently it slips back again into the gall-bladder, there to remain for a time, with little comparative inconvenience to the patient We need scarcely add, therefore, that the evacuations from the bowels should be carefully examined, inasmuch as the discovery of a calculus cannot fail to afford relief and comfort to the. mind of the patient. The treatment of calculous jaundice should be specially directed to three points:— 1. To facilitate the progress of the inhering concretion. 2. To mitigate the pain and other symptoms of irritation. 3. To guard against the inflammation which is to be apprehended from the irritation of the calcu- lus. In endeavouring to fulfil these indications, opium, may be regarded as our sheet-anchor. The first dose, consisting of one or two grains, or an equivalent proportion of the sulphate or acetate of morphia, may be advantageously combined with five or six grains of calomel. If the pain and sickness do not abate, a grain of opium may be repeated at the end of the first hour, and reiterated, after similar or shorter intervals, until ease be pro- cured. After a few doses have been given, a solu- tion of some neutral salt, particularly the sulphate of magnesia, either with or without the carbonate, or the carbonate of magnesia with lemon-juice in an effervescing form, may be administered, in combi- nation with some aromatic water, and repeated at fittin«- interval-*, until a free evacuation from the bowels is obtained. Soda-water, well charged with carbonic acid gas, or simple saline draughts in, state of effervescence, are sometimes useful in allaying the urgent vomiting. If opium by the mouth should not procure ease, a drachm of the tincture may be mingled with a few ounces of thin starch or barley-water, and administered as an enema : prior to which, however, it is sometimes advisable to throw up a large quantity of warm water, which alone sometimes proves very soothing to the patient. As soon as possible, recourse should be had to a warm bath, in which the patient mis; remain until a degree of faintness supervene,—a state of relaxation peculiarly favourable to the passage of the calculus. Should these various methods be unavailing, and the patient be in a state to bear depletion, it will be expedient to with- draw from ten to sixteen ounces of blood from the arm, in a full stream, and, if practicable, while in the bath and in a half-erect posture. Topical bleeding may be also needful if the continued irritation of the calculus indicate inflammatory action, which may be apprehended from the pain becoming more constant, and accompanied with tenderness on pressure. Emetics have been strongly recommended in calculous jaundice, and are doubtless powerful agents, though not always safe ones. When we consider the structure and the tortuous course cf the common bile ducts, as well as the sharp and angular forms of the calculi, we shall not regard, without considerable apprehension, the action of a powerful emetic. In many instances inflamma- tion, adhesion, and actual obliteration of the ducts, have resulted from the spontaneous passage of I calculus. Is it not, then, highly hazardous forcibly to impel these irritating substances against the already irritated mucous lining of the tubes ? Nauseating doses of ipecacuanha may, how- ever, prove safer and more availing, if the patient be not already in a state of nausea. Such an exception is, however, very uncommon. The ad- vantage to be expected from nauseating doses is of a twofold character. We may hope to pro- mote more general relaxation, ns well as to aug- ment the biliary secretion; and thus, while relax- ing the affected duct, and carrying down an in- creased flow of bile, nature may be assisted not a little in her efforts to expel the irritating substance, We have already stated that the bowels are sometimes in a relaxed state. In other cases, how- ever, they are obstinately constipated, and require strong and repeated doses of active purgatives, such as calomel, with the compound extract of colocynth, and an additional quantity of aloes, Even after the expulsion or retreat of the calculus, it will be desirable to exhibit occasionally a mer- curial purgative, at the same time supporting the tone and regular action of the chylopoietic organs by small doses of a neutral salt in some mild bit- ter infusion. We have mentioned hydatids, worms, and other extraneous matters, as" occasionally producing jaundice. In some instances substances may he passed by stool which will enable the physician, in subsequent attacks, to form a reasonable conjec- ture respecting the nature of the obstruction. But, JAUNDICE. 95 generally, no such intimation can be obtained, j The treatment, however, of jaundice from such causes must be very similar to that recommended for the removal of calculi. II. Jaundice arising from Diseased States of the Liver, Gall-bladder, or Biliary Ducts, will of course be attended by the symp- toms peculiar to each affection, in addition to those which characterize an obstructed state of the biliary passages. General or partial hypertrophy of the liver (a state not uncommon in great eaters); a tuberculated or schirrhous condition of that organ ; with many other forms of disorgani- zation, may so interrupt the egress of the bile as to occasion jaundice. When the disease is de- pendent on such causes, there is sometimes no pain, or pain of a less acute, though more con- tinued, character. The approach of the super- vening jaundice is also generally gradual; and symptoms of hectic fever too often succeed. It is a remarkable circumstance that, notwithstanding the prevalence of liver complaints, calculi are rarely found in the interior of that organ. Mor- gagni affirms, « vix uno in jecinore mihi olim ac- cidit ut invenirem ; Valsalva? autem in nullo, quod sciam." (Ep. xxxvii. Art. xi.) Dineased conditions of the ducts themselves form, we believe, more common cases of jaundice than is generally supposed. Of these, inflamma- tion and its consequences are among the principal. The mucous tissue of the ducts may become ulcer- ated, or so adherent as actually to obliterate the canal. It may, also, be so studded with tubercles as to be no longer permeable to the bile. Jaundice from such causes is often incurable and fatal. III. Our third general division of jaundice com- prises those morbid states of the Duodenum, which have been found to occasion the disease. Of such we may specify the following: 1. viscid mucus adhering to the inner membrane of the bowel, and sealing up the opening of the ductus communis choledochus. 2. a highly tur- gid or inflamed state of its mucous membrane. 3. a thickened, tuberculated, or otherwise disorgan- ized condition of the duodenum. 1. Viscid mucus, we are persuaded, is a frequent cause of temporary jaundice. Many of the cases which have been gratuitously attributed to spasm, were probably of this nature.* Tf we attentively ob- serve the peculiar structure of the termination of the common duct in the duodenum, we shall more accu- rately conceive how readily its small orifice, in the midst of a papillary projection, may be closed up by a thick and tenacious layer of mucus. Such a cause may be reasonably inferred when the dis- ease has come on rather suddenly, has been unat- tended by acute pain or other inflammatory indi- cation, yet has been preceded by dyspepsia and a torpid state of bowels. A mucous film upon the tongue, and the absence of the usual marks of chronic visceral disease, will give additional pro- bability to the opinion. A large dose of calomel, followed by a draught containing magnesia and rhubarb in infusion of senna or some other vehi- cle, will sometimes quickly remove the disease. Much circumspection as to diet, the regular use of * No special reference is made in this article to " spas- modic jaundice," because we have no evidence of its existence. active exercise, with an occasional recourse to pur- gatives, may equally ensure a freedom from re- lapse. 2. A turgid or inflamed condition of the mu- cous membrane of the duodenum probably seldom exists without the lower portion of the common bile-duct being similarly affected. This form of disease is characterized by uneasiness or pain in the course of the bowel, which sometimes becomes tender on pressure, the uneasiness being more particularly felt at the expiration of three or four hours after eating, and being often accompanied with vomiting. The tongue has usually a white or yellow surface, and there is considerable thirst. The pulse is also somewhat accelerated. In dis- tinguishing this affection from a diseased state of the pylorus, attention should be paid to the period after eating at which the vomiting occurs. Where the pylorus is alone affected, vomiting generally commences within two or three hours of the meal, and affords almost immediate relief. In the chro- nic inflammation of the duodenum, of which we are treating, the vomiting seldom occurs until four or five hours have elapsed, and does not alleviate the distressing sensations of the patient. He gains, however, sensible relief by taking a tea-cup full of warm fluid, which seems to excite an in- creased peristaltic action, and thus to liberate the oppressed duodenum from the undigested mass. It is of extreme importance to overcome this kind of jaundice as soon as possible, lest disor ganization of the duodenum, obliteration of the orifice of the bile-duct, or adhesion of its sides should ensue. Whether simple turgescence or actual inflam- mation be the cause, the treatment should be essen- tially the same, varying only in degree. A mode- rate bleeding from the arm, if the strength of the patient admit of it; repeated local depletion; the warm bath ; counter-irritants, particularly in the form of the antimonial ointment; with mild doses of saline aperients, and the most scrupulous at- tention to diet,—constitute the treatment which experience, no less than general principles, points out as best adapted for the purpose. IV. Jaundice produced by the pressure of enlarged contiguous viscera is of frequent occurrence, although less susceptible of relief from medicine. Cases of simple distension of the transverse colon, from a collection of impacted freces, are, of course, to be generally removed by appropriate remedies. Compression, too, by the gravid uterus, obviously admits of a natural cure. But a scirrhous enlargement of the pylorus, or of the round head of the pancreas,—two of the most frequent causes of this species of jaundice,—are among the most intractable as well as the most distressing disorganizations which human nature can sustain. In these cases, the most deplorable depression of mind, and an extreme degree of emaciation, are often observable. We have already alluded to some points of diagnosis in reference to the enlargement of the pylorus. As the disease advances, the tumefaction will be dis- tinguishable by the hand : so may also, generally, though with more difficulty, the enlargement of the pancreas. Affections of the head, irrespective of any pre- vious disease in the biliary organs, have been sup- 96 JAUNDICE-KIDNEYS, (DISEASES OF) ~~b7th, may be employed. In the more chronic form, remedies have been prescribed by some, the posi>d to occasion jaundice. Where, however, a serious injury has been inflicted on the head, such, for example, as is sometimes occasioned by a jump or a fall, it is highly probable that the liver or its appendages received some simultaneous injury, although the effect was not so quickly perceived. This is also the opinion of the judicious Aber- crombie. We have, however, long felt assured that the state of the brain and nervous system has been too little considered in the pathology of jaun- dice. When we regard the influence of the brain and nerves in secretion generally, as well as their influence upon the moving powers, we may rea- sonably suppose that any considerable deviation from their sound and vigorous condition will be likely to lessen or deteriorate the biliary fluid; and also, by withholding a due supply of nervous energy from the moving forces, retard its trans- mission through the biliary passages into the duo- denum. The remarkable influence which power- ful emotions have upon the secretion of bile, and probably, also, on its propelling powers, should lead us more attentively to mark this connection, and the morbid changes thence resulting; by which attention, we may hope, at some future period, to clear up many obscure points relating to the biliary secretion, both in its healthy and diseased states, and ultimately arrive at more suc- cessful methods, not only of removing jaundice, but also, in many instances, of preventing its occurrence. T H BuRDER. [Jaundice of the Infant, Icterus In- fantum, Yellow Gown or Gum, is a common affection of children everywhere. It comes on soon after birth, without any obvious cause, continues for some days, and disappears: the only other symptom generally observed being, perhaps, unusual drowsiness. It has been pre- sumed to depend upon some irritation of the in- testinal canal, resulting from the digestive system being called into active exertion for the first time, and receiving a new stimulus from the maternal milk. It is more probably owing to the ductus communis choledochus being obstructed by inspis- sated mucus, or by the meconium, which has col- lected in the intestines during utero-gestation. By some, it has been referred to too viscid a state of the bile; and by others to a congested condition of the liver. It is, however, an affection of no consequence. Even in torrid climates, recovery is so general, that opportunities have not occurred for discovering the precise pathological condition by dissection. It rarely exists at birth, but is commonly observed from the third to the seventh day—seldom in the second or third week; and terminates in death in the course of a week or two. The disease would generally yield, probably, without any treatment; but inasmuch as the cause would seem to be, in many instances at least, obstruction of the choledoch duct, it may be well to facilitate its removal by gentle laxatives, as the syrupus rhei, magnesia, or castor oil. The writer has never found it necessary to adopt any othir plan of treatment in the cases that have presented themselves to his notice; but should there be signs of hepatic inflammation, a few leeches, fol precise object of which is not very intelligible; and hence their action has been uncertain, if r*| null (Condie, A Practical Treatise on the Li* eases of Children, p. 520, Philad: 1844.) Robley Dunglison.] KIDNEYS, DISEASES OF. NotwithstanJ. ing the activity with which the kidneys perform their functions, the constancy of their action, and the extraordinary rapidity with which their secre- tion becomes affected, not only when other parti of the system are suffering under actual diseut, but even when they are simply and slightly disor- dered, these organs are not peculiarly liable te alteration of structure. On the contrary, as it I has been well observed by a distinguished pathc- j logist of the present day, " in the greater number of diseases, whether chronic or acute, we cannot discover by dissection any change in the structuie of the kidneys." Of the diseases incidental to the kidneys, the most important, perhaps, are ischuria rcnalia, nephralgia, and nephritis. To these might J be added diabetes, were pathologists agreed ss to its primary seat; but though several eminent writers have considered it to originate in the kid- neys, there are others of equal name and authority who have referred it to a different source. Ischu- ria renalis has been discussed in a former article; and it is proposed, likewise, to treat, under their respective titles, both nephralgia and nephritis. In the present article, it will be our object briefly to notice those other renal affections which, on account of the rareness of their occurrence, of the obscurity and uncertainty of their symptoms, or their hitherto uncontrollable nature, may pro- bably he deemed of minor importance so far as practice is concerned ; yet which, by those who are truly devoted to medicine as a science, can never be deemed insignificant or uninteresting. The renal affections which we are about to con- sider may conveniently be arranged, after the plan adopted by M. Andral, under three heads: the first comprising morbid conditions of the circula- tion of the kidneys; the second, lesions of nutri- tion ; the third, morbid formations. 1. Lesions of Circulation.—The kiJneyi are sometimes found gorged with blood—in that state to which the term hypereemia has been appropriated without any other alteration. One or both organs may be thus congested, and the congestion may affect both the cortical and tubular parts, or only one of them. When they are in a high state of hypcraemia, they assume a dark chocolate hue. The kidneys are also found in a state preciselj opposite to that just mentioned, namely, in a state of paleness or anrcmia, either partial or general, either complete or incomplete; sometimes existing in a few scattered points only. This is the con- dition of the kidneys which is frequently observed in persons who have sunk under chronic diseases, especially in dropsical patients, and those who have been the subjects of the affection named by Dr. Good marasmus anaemia. When thu paleness exists in an exquisite degree, it may be lowed by an emollient cataplasm, and the warm , regarded as in itself a disease, but hitherto it hai KIDNEYS, (DISEASES OF THE) 97 not been discovered to occasion any functional derangement during life. The yellow colour, either general or partial, which is occasionally observed in the kidneys, is probably owing, as M. Andral has remarked, to a less advanced stage of anaemia. It may suffice thus briefly to have noticed that congestion of the kidneys, or extreme paleness of them, may occur without their presenting any other morbid appearance. Such instances, how- ever, are rare; hypereemia, as well as anaemia, is usually found in connection with other degenera- tions of those organs: the former, for example, conjoined with softening, or with induration together with hypertrophy ; the latter with soften- ing, or occasionally with induration and atrophy. 2. Lesions of Nutrition.—The kidneys are sometimes much larger than natural, though otherwise unaltered. Both kidneys may be thus affected, but more commonly the hypertrophy is confined to one only. As was observed while treating of ischuria renalis, great augmentation of volume of one kidney is not unfrequently met with when the other is, by disease or obstruction, rendered incapable of performing its office. The enlarged gland takes upon itself the duty of its fellow. Hypertrophy of the kidney seems occa- sionally to depend upon its being doubly nour- ished, by receiving its supply of blood from two renal arteries. This state of kidneys, generally combined with increased vascularity, is the most usual morbid appearance observed in cases of dia- betes. An extreme paleness of their tissue, with softening, has indeed been often mentioned as the principal alteration which takes place in them in that disease ; but in various cases upon record, and in every instance which has occurred in our own experience, the kidneys have been more vas- cular, and generally larger than natural. To this variety of morbid alteration—hypertro- phy—may, perhaps, be referred those cases where the kidneys are united by an intermediate sub- stance ; a sort of middle lobe, resembling them in its texture, and passing over the vertebral column from the one to the other. With respect to the nature of those hard, whitish, globular bodies, of various sizes, which are mentioned by authors as existing in the cor- tical substance of the kidneys, and which in some few instances have been detected in the tubular substance also, little is known. Some have re- garded them as serving to secrete the urine, while others have supposed them to consist of a mass of vessels interlaced : but it is clear that granula- tions like these sometimes constitute a really morbid state. They nearly resemble the yellow granulations of the liver, which Laennec thought an accidental tissue, and to which he gave the name of cirrhosis,- but which, in all probability, are the result of an unusual development of one of its elementary tissues, namely, of its white sub- stance. These granulations in the kidneys are sometimes thinly scattered, sometimes so very numerous as to leave hardly any trace of their cortical portion, and even to occupy the intervals between the cones of the tubular portion of them. Such a state of the kidneys may, it would seem, produce dropsy ; for in various cases of dropsical patients no other morbid appearance of importance Vol. III.—13 i has been detected. Although, as M. Andral ob- serves, it is difficult to comprehend how dropsy is produced by this affection, the fact is nevertheless certain. [Under the head of Dropsy, (vol. i. p. 707,) attention has been drawn to the Granular Disease of the Kidney, Morbus Brightii, which is attended with the secretion of albuminous urine — hence termed Albuminuria. Yet the appearance of albumen in the urine is by no means diagnostic of this condition of the kidneys, as has been shown by the observations of the writer, and of others, (Practice of Medicine, 2d edit. ii. 29, Philad. 1844); and cases have been published recently, in which, on the one hand, Bright's disease existed without albuminous urine; and on the other hand, albuminous urine was present without Bright's disease. We cannot, indeed, with certainty, infer the existence of any particular organic disease of the kidney from the existence of albuminous urine. By those who look upon all morbid derange- ments to be the result of inflammation, granular disease of the kidney has been thus regarded, and hence the term nephritis albuminosa, which has been given to it. Like other morbid degenerations, however, it is owing to a vice of the system of nutrition, which is inexplicable. (Christison on Granular Degeneration of the Kidneys, Edinb. and Philad. 1839 ; or an abstract of the same in Tweedie's Library of Medicine, 2d Amer. edit. iii. 271, Philad. 1842; also, Rayer's Traiti des Maladies des Reins, 2e livr. Paris, 1837; Martin Solon, De VAlbuminuric, &c, Paris, 1838, and A. Dalmas, Diet, de Med. xxvii. 364, Paris, 1843.)] The kidneys, again, are subject to general or partial atrophy. In the former case, one or both of them may be diminished in size, without being altered in structure, and without any symptoms of disorder of the urinary apparatus having been present during life. Such a condition of kidney may have been coeval with the patient's birth; or the atrophy may have been the result of mecha- nical compression; of a tumour in the vicinity of the gland ; or of a collection of pus formed around it. One kidney may be wholly wanting; and this defect may be either congenital, or the consequence of disease. Of the former occurrence, a remark- able example has been given by Morgagni, Letter 31, Art. 25. In the patient there referred to, there was no trace of the left kidney, but the de- ficiency was supplied by the right, which was double the natural size, and furnished with a double pelvis and ureter; and both ureters went to the right side of the bladder. When one kid- ney has been destroyed by disease, no inconveni- ence may arise, provided the remaining one be sound ; but if that be also degenerated, it is obvious that the patient will experience much and severe suffering. An instance is given by M. Andral, where dropsy, of which the organic cause could not be discovered during life, was ascertained to have arisen from great disease of the urinary appa- ratus ; the left kidney was totally gone; the right was enlarged, softened, and studded with those whitish granulations which have been already noticed. Several curious varieties in the form and the situation of the kidneys are occasionally met KIDNEYS, (DISEASES OF THE) with ; but they can scarcely be considered as dis- eases, or, if they be so considered, they are not to be recognised by any peculiar symptoms, nor can they ever be influenced by medical treatment. The morbid states we are next to mention, are softening and induration. The former state is not unfrequently conjoined with turgescence or hyperemia, and this combination may be regarded as affording strong evidence of inflammation. In patients who, during life, have suffered under symptoms of nephritis, a very soft state of the kidneys, with intense redness, has been observed. The same condition has also been found accom- panying certain chronic affections of the bladder, as thickening of its inner membrane. There is a peculiar softening of the kidneys, which has been described by Dr. Baillie, and by Mr. Wilson, in his lectures. The kidneys are converted into a soft loose mass, resembling in appearance common sponge. When shaken in •water, the parts all separate from each other, somewhat like the unravelling of the shaggy ves- sels of the placenta. In one such case, small shreds, apparently portions of blood-vessels, had been passed by the urethra; and upon examina- tion after death, Mr. Wilson conceived that they might have come from the kidneys during life. This is one of those lamentable states of disease over which, even if known to exist, our art can exercise no power. There is another kind of softening, in which the substance of the kidneys is extremely pale, or of a grey tint. This alteration has been found where no symptoms of the disease of the urinary organs had manifested themselves. Induration of the kidneys may be attended by congestion or by paleness of their tissue. In the former variety, the organs are generally enlarged ; in the latter, they are also occasionally enlarged, but most commonly diminished in size. In the pale induration, the kidneys, though firmer than ordinary, may yet retain their natural structure ; or they may be almost as hard and as white as cartilage, their natural structure being entirely lost. This is the state which has been called scirrhus of the kidney. It is very rarely met with, and the symptoms attending it arc not to be distinguished from those which belong to other renal affections. When both kidneys are thus diseased, very little urine will be secreted, or there may be complete ischuria renalis. The remedies we must employ, must of course be those which have been useful in nephralgia and in suppression of urine. Opium and hyoscyamus arc more likely to afford relief than any other medicines. 3. Morbid Formations. —- Of the diseases belonging to this division of our subject, the most important is that very formidable and intractable malady first accurately described by Mr. J. Burns, under the title of spongoid inflammation; but more generally known by the appellation of fun- gus hxmatodes, assigned to it by Mr. Hey. Until of late years, it was commonly confounded with cancer, of which, indeed, it is still reputed a species by some writers of high reputation. In this light it is regarded by M. Roux. Mr. War- drop has named it soft cancer; and Mr. Langstaff has remarked that sometimes the scirrhous, medul- lary, and fungoid structures, are so blended in various parts of the same subject, that they »p. pear like different stages of morbid growth, ir»j the difficulty the pathologist experiences is in de- ciding whether the disease is of the cancerous 01 hsemodotal kind, or whether they are not of /fe same class. The same author refers to Sir Eve- rard Home, as stating that the fungoid and the cancerous sore are the effects of one disease, only varying according to the structure of the paru which it attacks. As, however, it is now ascer- tained that the same structure, the female breast for example, is liable to either disease, and that fungus hsmatodes has been observed in almost every part of the body, the position of the last- mentioned pathologist is no longer tenable. It may be admitted that, in the malignancy of their character, as well as in some other points, fungus hcematodes and cancer bear a strong resemblance to each other; but at the same time we must maintain that the former disease wants the pathos*. nomonic signs by which cancers are distinguished. (See Fungus Hjsmatodes.) Mr. Wardrop first noticed fungus hfematodes a affecting the kidney ; but he acknowledges that, in the case he relates, the morbid alterations of structure would not have been alone sufficient to warrant him in calling it fungus haematodes. He conjectured it to be such, because there was fungus haematodes over the hip-joint. Since the publica- tion of his work, however, several well-marked cases have been given in detail by M. Langstaff In one of these, the subject of which was a man aged seventy, affected by hemiplegia for several years, the symptoms were, for a length of time, difficulty of voiding the urine, which was usually tinged with blood, and afterwards retention; great pain in the region of the left kidney, and uneasi- ness of the rectum. He died apoplectic. In another very interesting case, that of a young lady, the symptoms were frequent desire to relieve the bladder, and in the course of a few hours an immense quantity of limpid urine was discharged, without alleviation of the urgent propensity to void more ; then, the irritability of the bladder in- creasing, arterial-looking blood was discharged in considerable quantity. Some doubt existed at first as to the source of this hemorrhage; there was some reason for suspecting it might proceed from the uterus, but the introduction of the catheter at once settled the question. After several recur- rences of hemorrhage, accompanied by great irri- tability of stomach and bilious vomitings, the dis- charge of blood ceased for a time, but then the urine was very turbid, and deposited a muco- purulent sediment. About six weeks subsequent to the first attack, dull pain was complained of in the right side, and upon examination a tumour was distinctly felt in the right hvpochondrium, and traced into the iliac region : there was pain upon pressure, and pulsation of the part. The discharge of blood afterwards returned at intervals, and the tumour increased greatly, in despite of all the means that could be devised for checking its growth. The patient's general health of course suffered dreadfully, and sometimes she appeared to be reduced to the last degree ; yet, in the in- tervals of the attacks of pain, sickness, and hemor- rhage, she rallied in a surprising manner; nor was it until five years and a half from the com- KIDNEYS, (DISEASES OF THE)—LACTATION. 99 , mencement of her sufferings that she sank under .them. Upon examination after death, it was ^ found that the right kidney occupied the principal part of the abdominal cavity : the diseased mass, , with a portion of the liver, which adhered to it, .weighed eleven pounds and thirteen ounces. It ^was almpst entirely formed into protuberances of .different sizes, and the peritoneal surface was ^greatly condensed. When that part of the tumour t which constituted its chief bulk was cut into, it ' was found to contain a coagulum of blood, not adhering to the sac, and weighing three pounds, ^and composed of concentric layers, as in an aneu- rism which has formed rapidly. The left kidney, which weighed twelve ounces, was much altered in structure, being chiefly occu- pied by pulpy tubera, which were rendered red y by minute injection. ' In the Medical Gazette for May, 1831, is re- f lated a case of fungus haematodes of the kidney, -' in a subject only four years of age. In this in- stance, the symptoms of renal affection were so trifling, that no suspicion existed in the mind of the medical attendant that such affection was the • sole, or even the chief cause of the little patient's distress. It had been conjectured, a3 in Mr. • Langstaff's case just mentioned, that the liver was enlarged ; but the apparent hypertrophy of *'■ that viscus was occasioned by the enlarged kid- ney, which pushed it upwards and outwards to- wards the diaphragm. These unhappy cases have hitherto resisted every mode of treatment. When fungus haematodes attacks external parts, it is still one of the opprobria medicinae ; what, therefore, can be expected.from our art, when its ravages are obscurely going on in internal organs 1 The formation of hydatids has been stated as being no uncommon disease of the kidney. It would, however, seem that the true hydatid is not often met with in that situation; while those cysts with thin and nearly transparent parietes, and which contain a limpid colourless fluid, very like water, but having some coagulable matter, are of frequent occurrence. These may be dispersed over the surface of the kidney, or be imbedded in any part of its substance. They often attain an enormous size, so as to occupy by much the larger portion of the gland; and they vary in number, from a single one to many hundreds. Each is a distinct bag, and does not contain others within it. It is probable that these cysts depend upon a mor- bid alteration of the structure of the kidney. In the true hydatid the cyst is thicker and much firmer : and, when cut into, appears lami- nated. Within the bag there is sometimes only one hydatid, but generally there are a considerable number; some attached to its parietes, others loose and floating in the fluid. These hydatids sometimes have numerous others adhering to their inner surface, or floating freely in their cavity. (See Hydatids.) We possess no other distinct evidence of the presence of hydatids than that which their being passed by the urethra with the urine affords. All the other symptoms, such as pain of back, symp- tomatic fever, nausea and vomiting, belong equally to other renal diseases. Every modification of treatment has been tried, when their existence has been positively known, or has been suspected, but in vain. An artificial outlet cannot be made for them. When they obstruct the flow of urine, as sometimes happens, the bougie or catheter must be employed. Under the steady exhibition of tur- pentine the pain of the loins has been known to cease, as well as the passing of hydatids; but in many instances the same remedy has totally failed. The muriated tincture of iron has been given, but with no permanent good effect. Of the remaining morbid formations in the kid- neys, tubercle is the only one which merits the least attention. It is very rarely found in them, and, when it is, generally exists in other organs also. The tubercle of the kidney is said by Dr. Baillie to resemble exactly the common tubercle of the lungs. Fatty matter and gelaliniform matter are now and then observed in the kidneys, and they have been found converted into a bony or earthy sub- stance. But these morbid appearances are of ex- treme rarity. We have thus endeavourod to furnish a sketch of those diseases of the kidneys which, though hitherto little understood, could not, in a work like the present, be passed .over with propriety. In the actual state of our knowledge, our descriptions must necessarily be imperfect. The period may be distant in which their nature and symptoms will be thoroughly comprehended. The most pa- tient attention to the phenomena of certain dis- eases, the most diligent search into the morbid changes produced in the structure of parts by morbid actions, may for a long time seem to be unproductive of any important practical results; still, patient investigation should never be aban- doned. It may be the good fortune of others hereafter to elucidate what is obscure in the affec- tions of which we have just given a brief account; it was our duty to record what is already known respecting them. H w Carter. LACTATION.—Lactation in the human fe- male, when naturally conducted, cannot be called a disease; but even under the most favourable aspect there are often circumstances which require attention and regulation, both for the purpose of alleviating pain and of preventing mischief. There are, moreover, so frequently interruptions to this usually healthy process, and there are so many important questions connected with the flow of milk at various periods, that it becomes necessary, in a work on practical medicine, to discuss them, although somewhat briefly. The close sympathy between the uterus and the mamma? is evident even in the unimpregnated con- dition. At puberty the breasts enlarge and their glandular structure is developed; a day or two before menstruation, and during the period itself, the breasts become tumid and more or less painful. There is an affection which may be termed spu- rious pregnancy, described by Dr. Gooch, where, apparently from uterine irritation, the breasts are swollen and affected with shooting pains, and even a serous fluid resembling thin milk oozes from the nipple, being precisely what takes place in real pregnancy, wanting only the darkened areola. In some diseases of the uterus, particularly in hyper- trophy of that organ, a similar state of the breasts is often observed. In real pregnancy the altera- 100 LACTATION. tion in the breasts is strongly marked, and the quantity of milky serum which is secreted is sometimes very copious, especially towards the close of utero-gestation. Sauvages mentions an instance where as much as a pint and a half was daily poured out as early as the fifth month. Many women, however, show no appearance of milk at all before delivery, who yet have abundance after- wards. After parturition it is usual to place the child to the breast within the first twenty-four hours, partly to draw out and form the nipple be- fore any hardness of the breast occurs to render that difficult, and partly to encourage the flow of milk,—for at a later period the contact of the child's mouth will immediately excite it. With first children there is rarely any quantity secreted before the third day ; about that period, but often a day or two later, the breasts become hard and swollen, hot and painful; the pulse is quickened, the skin above the natural temperature, the thirst urgent, the sleep broken and troubled with un- pleasant dreams, and the sensorium disturbed, so that the patient, whilst yet awake, will fancy 6trange objects about the bed. The process goes on, more or less rapidly, till the milk is at the height, as it is termed, when the breasts are ex- tremely hard, and the gland is felt knotted and loaded, and is at the same time very tender; the swelling may extend quite to the clavicles and under the arms, the axillary glands being similarly affected ; a small quantity of milk will often ooze out from the nipples, particularly if the breasts be fomented, or gently pressed with the hand. If the child be put to the breast, the action of suckling is attended with great pain to the mother, but fol- lowed by much relief. As the milk flows, the hardness diminishes, and the swelling subsides. After a few hours, if the milk be freely and fre- quently drawn off, the sensations become more comfortable, the pain is removed, the breasts are only distended when the child has been long away, the pulse and skin are restored to their natural state, and the process of lactation is then fairly established. In the management, up to this period, much may be done for the relief of the patient. As soon as the symptoms begin, a purgative may be ad- ministered with great advantage, and one which contains the neutral salts in combination, as it will promote watery discharges from the bowels, is preferable: this should be repeated in twenty-four hours, or earlier, if the case is severe. There is distressing thirst, but if we allow a too free indul- gence in liquids, the distension of the breasts is increased; it is therefore better to allow only a small quantity of drink at a time, and perhaps nothing is so effectual in a small bulk as an effer- vescing saline draught frequently repeated. As a new-born infant will often experience much diffi- culty in drawing out the nipple of a hard and swollen breast, or in extracting the thick milk itself, it is often advisable to have this done by an older child or a grown person, or by artificial means. These consist of various sorts of breast- pumps, where a smooth-edged glass tube is placed over the nipple, and a vacuum being produced by suction or by syringes, or by heat, the milk is thus drawn off, and the buried nipple made to project. Great benefit may be obtained by fomenting the hardened breasts with hot water, or by applying mild poultices, which promote the easy flow ef the milk and relieve the distension. This is ih, often effected by small wooden bowls soaked ii boiling water, and wrapped up in flannel, which are then placed over each breast. As a more pa. manent application, hare-skins are oftstn u«J cabbage-leaves were also formerly much in vog« to promote a copious perspiration over the surface; the smell, however, is very unpleasant, and the same advantage may be gained by oiled silk. The milk first drawn has a purgative quality, and thus serves to carry off the meconium which is loading the large intestines. On this account, when a child does not get the first draught of the breast, from being nursed by a wet-nurse, or from being brought up by hand, a gentie purgatix should always be given ; diarrhoea of an irritable character, and even convulsions, often being pro. duced from retained meconium. In this country it is usual to give a purgative under all circum- stances, but it is not customary in many parts of the continent, and it is doubtful whether it be not often superfluous. By the experiments of Dr, Robert Lee, it would appear that the meconium is an excrement, and does not contribute to nourish- ment ; but that above the situation of the meco- nium a quantity of highly nutritious albumen is found in the intestines, serving for the sustenance of the infant till lactation is established. A pur- gative given before that period will therefore carry off this substance, and artificial nourishment must be given to make up for the loss of the natural provision. The milk varies considerably in'condition during lactation. At first it is thick, yellowish, and having a very large proportion of cream ; several days elapse before it possesses its natural appearance, which should be thin, bluish, and sweet. The quantity of cream varies very much according to the diet, and the frequency with which the breasts are drawn. Some milk has a decidedly saline taste; and at other times it has been distinctly bitter, so that the child will turn away from the breast in disgust. Its taste and qualities may be easily affected by articles of diet, by passions of the mind, repletion, hot rooms, &c. and the child is more or less disordered by the alteration. Medi- cines will often affect the milk in a very striking manner ; a purgative given to the nurse will fre- quently act violently upon the child, without in the least affecting the individual herself; in the same way, alkalies given to the nurse will relieve acidity in the child's stomach ; and mercury given through a similar medium will cure syphiislje symptoms in the infant at the breast.* Milk has been said to be sometimes black or green, but there is in such cases most probably a mixture of blood, from the exterior or interior of the nipple. The writer has seen four instances where it was of a golden yellow colour, and where, upon standing, a thick layer of bitter cream,»« * On the authority of Mr. Keate, it may be here stated that a foreign gentleman, a patient of his, was in the habit of regulating his hepatic system, when there was a deficiency of bile in his motions, by taking asses' milk medicated by giving the animal a cenain quaniity of • | mercurial preparation (the nitrate of mercury). "N* | ettect was very marked, and he could bear mercury i« , uo other shape. LACTATION. 101 ;. yellow as pure bile, floated on the surface. In . neither of these cases was the patient jaundiced; .but a very copious flow of bile being kept up from .the intestines by mercurial purgatives, alter a few days the yellowness gradually disappeared ; the child, till then, having been much griped and affected with diarrhoea. In no cases where wet- nurses have been jaundiced, has the writer seen the milk yellow; and it is no uncommon thing for them to become thus disordered, upon a sud- '• den transition from poverty and a scanty diet to a full and luxurious mode of living. Milk will dis- ~ order an infant from merely being too rich, with- out its being otherwise altered in character. The - remedy here will consist in purging the nurse, • making her take plenty of active exercise, and putting her upon a more spare diet. The proper- ties of the milk will also be considerably influenced by pregnancy or by menstruation. There are some popular errors upon this point, which it is not difficult to expose. One is, that women will not become pregnant during lactation. This is far from being the case, and Mr. Roberton of Manchester (vide Edinb. Med. and Surg. Jour- nal, No. 110) has taken the trouble to inquire minutely into the result of 160 cases, in which he found that eighty-one women had become im- pregnated during suckling. Mr. Roberton has stated "that the appearance of the catamenia du- ring lactation does not appear to have any in- fluence indisposing to conception." In this respect the writer's experience leads him to a different conclusion : he is decidedly of opinion that those women who menstruate during pregnancy will more readily conceive than those who do not; and he has also remarked, as Dr. Hamilton has done, that both these occurrences are more com- mon with first children ; hence women under such circumstances are not, cscteris paribus, so eligible for wet-nurses. Dr. Mason Good has recom- mended cohabitation with the husband during lac- tation, as likely to increase the quantity of milk ; arguing upon the fact that the Tartars are accus- tomed to irritate the vagina of their mares for a similar purpose. The objection to his proposal will only apply to hired wet-nurses, lest they should become pregnant. Wet-nurses have very frequently recommended themselves to the writer on the plea that they have still continued to men- struate, by which they believe that their milk is renewed, as they term it, every month, so as to be rendered fit for much younger children than it would otherwise have been. This occurrence, however, much impairs the milk, in its probable duration, and in its properties at the period itself. The infant becomes unusually fretful, brings up the milk by vomiting, and has frequent watery motions of a spinach-green colour. These symp- toms are so peculiar, when arising from no very obvious cause, that it may be generally safely guessed that the nurse is either menstruating at that moment, or will do so on that day month ; for it is not uncommon to find the effects on the child brought on, although the alteration in the uterine condition of the nurse is not complete. One of the most early and most troublesome attendants upon suckling is soreness ofthekiipples, as the pain recurs as often as the infant is put to the breast. Very few escape some degree of ten- derness, with first children especially, but the in- convenience is soon obviated, and the delicate skin becomes callous, like the fingers of a harp-player —an effect which may be hastened by some slightly astringent or gently stimulating lotion, as green tea, brandy, weak solutions of the sulphate of zinc or of alum. If more severe and intractable, a solution of one to two grains of nitrate of silver in one ounce of rose-water will be found of service. Should the skin become excoriated, or should a crack take place at the junction of the nipple to the areola, a shield of glass, wood, ivory, or silver, should be used, with an artificial or pre- pared cow's teat, through which the child may suck without biting or much disturbing the nipple. The surface of the sore may then be freely touched once a day or oftener with the lunar caustic, and in the intervals the part may be kept well smeared with ointment containing honey, or a minute quantity of Peruvian balsam. Preparations con- taining lead or mercury in any form are scarcely advisable, as they may be swallowed by the infant. Where the surface of the nipple is not chapped, but unusually hot and dry, and very tender to the touch, all astringent lotions and stimulating appli- cations aggravate the mischief; the simplest oint- ments, of wax and oil alone, will be found to agree best, or the part may be covered with powdered gum arabic or a bread-and-water poultice. The dress should, in all cases, be carefully kept from irritating the sore nipple, by means of wax cups, shells, or glasses for the purpose. There is one species of sore nipple not often noticed by practitioners, (who are too apt to leave these cases to the management of the nurses,) which the writer has found more intractable than any others, and the means frequently of inducing the mother to give up suckling entirely, from the constant torture to which she is exposed. There is little or nothing to be seen but a small spot at the orifice of the nipple, which is elevated and irregular in appearance, extremely painful to the touch, and exuding a sanious ichor. When the child is put to the breast, the pain is most acute, and seems to come from the interior of the nipple and breast; and the first and last milk is generally mixed with blood. It would appear as if the in- terior or lining membrane of the lactiferous tubes was in a morbid condition. Little or nothing can be done for this affection. The free application of caustic to the external orifice, and poulticing the breast, has now and then effected a cure, along with careful attention to the stomach, bowels, and general health, which is highly essential. Those who have uniformly suffered from sore nipples on former occasions have frequently seemed to prevent them by using, previously to parturition, for several weeks, either an astringent or demulcent lotion, according to the state of the skin. Inflammation will occasionally attack the breast itself at any time during lactation, but most fre- quently at a very early period, when there has been exposure to cold, much trouble in the first management of the milk, or soreness of the nip- ples; it does not so frequently happen where the milk is at once driven back without suckling the child. If not immediately treated by leeches, by fomentations, and poultices, hot and frequently changed, or, as some prefer, by cold lotions, abscess 102 LACTATION. will take place, accompanied by great pain and much constitutional disturbance. The treatment of this state comes within the immediate province of the surgeon; but there are one or two circum- stances respecting milk abscess deserving of notice in this place. It is very customary when abscess is threatened, to persevere in keeping the child to the breast, or otherwise drawing the milk off; partly to enable the patient to continue suckling, and partly to prevent the milk collecting in and distending the inflamed breast. If the inflamed portion be not extensive, there is no objection to this, as a small abscess will not much interfere with the functions of the remaining sound parts ; but if the whole, or nearly the whole, of the breast be implicated, the pain of suckling will be very violent indeed, and the frequent disturbance and irritation will contribute to increase the inflamma- tion, and diminish or entirely obviate the chances of preventing the formation of matter. Should abscess be formed, and matter be felt fluctuating, the most experienced practitioners agree upon the propriety of puncturing early and freely; other- wise in such a peculiar structure most extensive mischief will take place, and the surface remain disfigured afterwards in the most unsightly manner. It is curious to notice in subsequent confinements how little the real glandular apparatus has been destroyed, even where large collections of pus have formerly been evacuated, so that the patient will sometimes be enabled to nurse with but little trouble; although from some partial obliteration of the ducts, there is always rather more difficulty in the flow of the milk. Milk Fever.—What is called milk fever, is an aggravated and morbid form of the healthy and natural excitement which takes place at the onset of lactation. The febrile symptoms are much more severe; there is a well-marked precursory rigor; there is great pain and throbbing of the head ; a flushed countenance; intolerance of light and sound ; the pulse is full, hard, and rapid ; the thirst excessive; the skin hot and dry, and the tongue covered with a thick fur. These attacks may be usually traced to a too stimulating diet, a heated atmosphere, much exertion and disturbance, or mental agitation. They are much less frequent than formerly, when great fires, loads of blankets, and brandy caudle were the usual appendages to a lying-in chamber. If the flow of milk be en- couraged, and gently yet freely drawn off"; if the room be kept cool; agitation soothed or avoided ; purgatives duly administered, and perhaps diapho- retic medicines; a remission of the symptoms will usually take place in a few hours, accompanied by a copious perspiration and tranquillity of pulse. On the contrary, by bad management phrenitis may supervene, of a very dangerous character ; when the milk will be entirely suppressed, and nothing but the free use of the lancet will save the patient. A very common expression is, that in such cases the milk flies to the head. In phlegmasia dolens the milk was also supposed to fly to the leg, and hence the French writers formerly called it, " depot du lait." It has several times happened in the writer's experience, that where bleeding has been had recourse to in inflammatory diseases with sudden suppression of milk, the serum of the blood, when separated by rest, has been white, opaque, and bearing nearly all the character, of milk, except the formation of cream on the surface, It may here be observed, also, that where the milk is driven back artificially, and active purgatives are employed, a great quantity of milk-like fluid may be generally seen in the motions. Depress- ing passions, fear, and anxiety, will suddenly drive off' every vestige of milk ; but the only genuine translation may be said to be those extraordinary instances where the milk has receded more or less rapidly from the breast, and a vicarious discharge has taken place from other parts, the general health remaining but little affected. The most common example of this is where the discharge has taken place from the vagina in the form of leucorrhcea; but it has also occurred from the fauces, the navel, the eyes, the kidneys, the whole surface of the mamma?, &c. Where the child is to be weaned, or where a mother does not wish to suckle, or is not able from constitutional debility, or local defect, or where the death of the child has taken place, it becomes necessary to " backen" the milk, as it is vulgarly termed. This may be done the most safely for the mother by her not being too impatient. If cold evaporating lotions are applied to the breasts, there is a more rapid dispersion of the milk, but there is more risk of fever, phrenitis, &c. It so happens, however, that these cold lotions rarely are allowed to act as such, for nurses in general are so par- ticularly careful to cover up the patient's neck with the bedclothes and wrappers, that the lotions very rapidly become warm fomentations. In the writer's opinion, the best and safest applications consist of stimulating liniments, applied warm and also constantly, by means of layers of lint or flannel. The breasts should also occasionally be gently pressed and rubbed with warm oil; and if they are very.hard and distended, a small quantity may be now anil then squeezed out or drawn olf artificially. The bowels are to be actively kept open by saline purgatives; the diet is to be low, and the quantity of drink lessened. It will be but a few hours before the extreme distress is mitigated, but it will be often several days before the milk is thoroughly dispersed, or the remedies can be dis- continued. The sensation of " draught of milk" in the breasts will sometimes be felt two or three times a-day for weeks afterwards. In weaning a child, however, it is often the plan to do it so gra- dually, by accustoming it to partial feeding for some time previously, that little trouble is at last experienced in dispersing the milk. It is still very desirable that opening medicine should be plenti- fully given, even under such circumstances; as from this discipline being neglected, patients will often suffer for months afterwards, with great de- pression of spirits, loss of appetite, feeling of weight and lassitude, and general ill health,—sen- sations which are soon relieved by having recourse to opening medicine. An excessive secretion of milk will sometimes be met with; but in nearly all these cases there is apparently some defect in the organization of the nipple, or the lactiferous tubes have lost their elastic property of retention, for in the intervals of suckBig a constant and very copious discharge of the milk lakes place. The daily waste and drain cannot exist long without materially affecting LACTATION. 103 the health and strength ; and unless the flow can be kept in check, there is no remedy except weaning the child, and repelling the milk altogether. Various plans have been proposed, but the trial is not often successful. Local strong astringent applications, as lotions of alum, oak-bark, zinc, &c, sometimes do good, but they are apt to effect too much, and drive away the secretion entirely. The astringent tonics internally, particularly the mineral acids, steel, kino, and alum, have occasionally been of service. Belladonna has been advised, both locally and in small doses internally. The breasts should be kept as cool as possible, and cold bathing be daily had recourse to. The period of lactation is generally one of the most healthy of a woman's life; but there are many exceptions to this; and many who have begun with success, by continuing to suckle too long, by a too limited diet, by much loss of rest, or by other causes, have had their own health and that of their infants considerably and even fatally impaired. A recent writer has attempted to de- fine the exact period to which suckling should be limited, as far as the advantage of the infant is concerned ; but all such definitions are constantly contradicted by experience. There is much fal- lacy also in the arguments to prove that protracted lactation is the cause of various infantile diseases, especially hydrocephalus. Putting aside altoge- ther the striking fact that the dangerous disturb- ance of dentition is proceeding at the same time, it may be allowed that hydrocephalus and the other diseases mentioned may and often do occur after or during protracted lactation ; but they hap- pen quite as frequently, and indeed more so, where a child has been brought up by hand, with- out the breast at all; or where it has been badly fed, or over-fed, whilst still suckling. In all the cases of mothers who have nursed their children for two years and upwards, in the class of life alluded to by Dr. Morton, it may be, perhaps, fairly assumed, from the known habits of the pa- rents, that the children have been fed at the same time, and generally fed upon exactly the same sort of food as would be more adapted to older children. " The child eats whatever we eat" is the common expression, though the child is still allowed to apply to the breast at pleasure, to pre- vent the chance of a fresh pregnancy. Many chil- dren, particularly in the higher classes, where hired wet-nurses are employed, are kept for a long time at the breast because they are backward with their teeth, have had their bowels disordered by a premature attempt at weaning, or because they are in delicate health ; but if hydrocephalus supervene in such instances, it is quite as likely that the previous disordered health may have been the cause, as the protracted lactation. In savage nations, in many parts of America, the east, and the polar regions, it is the constant custom for mothers to suckle their infants for two years at least, and without any of the pernicious conse- quences which Dr. Morton has imagined. (See Edinburgh Medical and Surgical Journal, No. 110.) It is certainly true, that if the mother's health be impaired by undue lactation at eithe*an early or a late period, the child will suffer from defec- tive nutrition, but in no other manner. [According to M. Desormeaux (Art. Lacta- tion, in Diet, de Medecine, xxii. 425, Paris, 1838,) some women are able to continue suckling almost indefinitely, provided the child be put to the breast. It is not uncommon, he says, in France to see nurses suckle three children in suc- cession, comprising a period probably of from 30 to 36 months; and cases are not rare of women who have suckled their children for four year3, and four years and a half. He himself saw a nurse from Normandy, who had suckled several children successively on the same milk for up- wards of five years; and a lady, worthy of all cre- dit, informed him, that she knew a woman who nursed five children in succession, so that her lactation continued at least seven years. It has been a common opinion, that when men- struation recurs during lactation, the milk of the nurse is unfit for the perfect nutrition of the child. M. Gendrin would on no account permit a woman to continue nursing after the catamenia had re- turned. The subject has been recently investi- gated by M. Raciborski (Dublin Medical Press, Aug. 2, 1843, cited in Amer. Journ. of the Med. Sciences, Oct. 1843, p. 455,) whose inferences are as follows :—contrary to generally received opin- ions, the milk of nurses who menstruate during suckling does not differ sensibly in physical, che- mical, or microscopical characters from that of nurses whose catamenia are suspended ; — the only difference which can be detected between the kinds of milk is, that, in most cases, the milk of menstruating nurses contains less cream during the menstrual period than in the intervals; hence arises the bluish appearance presented occasionally by such milk; and he concludes that a nurse should never be rejected merely because she men- struates.] Dr. Marshall Hall has well described the state of disorder of the general health in females, which is induced by exhaustion of the frame, arising from protracted lactation, or from the original powers not having been equal to the continual drain on the system. One of the earliest symp- toms of failure is a dragging sensation in the back, when the child is in the act of sucking, and an exhausted feeling of sinking and emptiness at the pit of the stomach afterwards. The appetite fails gradually, but entirely; there are thirst, a dry tongue, a quick feeble pulse; costive bowels, head- ach, with giddiness, lightness, and failure of sight. The skin is hot and cold alternately ; there are profuse night-perspiration; generally leucorrhcea, great debility, and emaciation. The memory is impaired; the spirits are weak, irritable, and de- pressed. [Occasionally, too, aphthous stomatitis occurs, and it would seem to occur more fre- quently in some localities than in others: (see Aphtha;.)] Symptoms resembling phthisis will sometimes come on, and mania is not an unusual result. Though much may be done in the first instance by the proper use of tonics, cold or sea bathing, change of air, a regulated diet, and local applications, to restrain the leucorrhcea; and though we may now and then effect a portion of good by partially feeding the child, yet the quickest and most effectual remedy is to wean the child. The different symptoms resulting from the exhausting process require appropriate treatment, according to 104 circumstances; but all treatment will generally fail, unless we remove the cause of exhaustion. Before leaving the subject of lactation, it may be remarked that males have also the organs for supplying milk, in a dormant state, which under peculiar circumstances have been excited into action, and have supplied milk in abundance, suf- ficient to suckle children. Instances have been given in recent times by Humboldt and Captain Franklin, and many others are on record. Very old women* and virgins have also had milk in considerable quantities, the nipples in all these cases having been frequently stimulated by the contact of the child's mouth purposely applied. [Several instances not only of very old women and virgins but of men having suckled children have been given by the writer in his Human Physiology, 5th edit. ii. 436, Philad. 1844.] It is by no means uncommon to meet with newly-born infants, of either sex, who have their nreasts turgid with a milk-like fluid, which is dis- persed with difficulty. c Locock. LARYNGITIS. —Of inflammations of the larynx there are many varieties, to which we mean briefly to allude before we enter upon a description of that formidable disease which has of late years obtained the title of laryngitis, and is the proper subject of this article. Beginning with the slighter inflammations, we may, 1st, advert to that affection of the membrane lining the larynx, which is distinguished by hoarse- ness, or complete loss of voice, and by slight cough, an affection which, arising from exposure of the body, or part of it, to a current of cold or damp air; from partial or general wetting; or from an incautious laying aside of some article of dress, especially during changes of the weather, is so slight, as seldom formally to be brought under the observation of the physician. 2dly. Similar symptoms not unfrequently occur in connection with common sore throat (cynanche tonsillaris), and for the most part they also form a case for domestic prescription, unless the inflam- mation is so considerable as to threaten suppura- tion. These two affections are chiefly prevalent about the beginning of winter and in the spring, and for the most part yield to confinement to the house for a day or two, and the antiphlogistic regimen. The latter affection, like the former, is of little importance, unless considered in connection with laryngitis, which has sometimes commenced like an ordinary sore throat attended with hoarseness; or unless it give rise to chronic disease of the af- fected part; for it is observable of both these slight inflammatory attacks, that when neglected, or when, from exposure to frequent vicissitudes of temperature, to foggy and cold weather, or to * A very interesting account is given (in the Medico- Cliirursii-al Review, for July 1KW) by Dr. Kennedy of Ashby-de-la-Zouch, of Judith Waterford, of that place, and now alive, with milk suit in her breast? at the age of eijjhty-one: rhe summary may be given in Dr. Ken- nedy's own words. "Here, then, are the remarkable circumstances of a woman who menstruated during lac- tation, who suckled children (many not her own, unin- terruptedly through the full course of forty-seven years (three years of which time she was a widow), and in her eighty-first year has a moderate but regular secretion of milk." LARYNGITIS. tie night-air, they are from time to time renewed, a state of permanent irritation is sometimes pro. duced which is indicated by hoarseness, slight mnco-sibilant inspiration, and cough, and by sow difficulty of swallowing; symptoms which, espe- cially in persons advanced in life, end in chronic laryngitis, a disease always intractable and often fatal." In these attacks, relief, if sought in time, may in general be obtained by bleeding, especially topically, and blistering ; by a course of calomel and ipecacuanha, or calomel and antimonial po*. der, one grain of each given three times a day, and continued until the gums become slightly affected by the mercurial; by pure air of mode- rate and equable warmth; and rest and quiet, 3dly. Sometimes the membrane of the larynx is inflamed in gastric fever, and in various fevers of the exanthematous order, especially in small- pox, measles, scarlatina, and erysipelas, fevers which we apprehend are all essentially gastric. In small-pox, the epiglottis and larynx are often inflamed and beset with pustules, from which very great distress ari&es. In the beginning of measles, inflammation of the upper part of the windpipe is so considerable as to give rise to an attack which, for a short time, advances with all the violence of croup. In the winter of 18U7, and more especially in the spring of 1808, when measles were epidemical in Edinburgh and the neighbourhood of that city, and of so unfavoura- ble a kind that we witnessed the death of mora than 100 patients in the course of a few months, the disease corresponding with the putrid measles of Watson, (Med. Obs. and Inquiries, vol. iv. p. 132,) not only was the larynx often affected be- fore the efflorescence took place, but in several instances after the rash had disappeared it becaine inflamed ; in all which cases, to the best of our recollection, the patients died. In one dissection which we procured, of laryngitis after measles, the following were the appearances discovered. The investing membrane of the epiglottis was considerably thickened, particularly at its edges; such also was the state of the membrane of ttw glottis; the sacculus laryngeus was nearly obli- terated, and, below the sacculus, ulceration had taken place. When the epidemic commenced, bleeding was often useful, but after it had conti- nued for some time, and had become more fatal, the attending fever being typhoid, bleeding ap- peared injurious; indeed we then observed that scarcely a child recovered which had been hied, so that bleeding was not had recourse to when the larynx became inflamed. Nor were blisters applied, most blistered surfaces having a strong tendency to run into ulceration and gangren* Were we again to be called to such cases, we would recommend immediate change of dwelling, a remedy not yet duly appreciated in acute dis- eases; an emetic and calomel, with small addi- tions of opium. We have frequently known inflammation HI scarlatina and in some forms of cynanche to affect the fauces, whereon perhaps a plastic membrane was formed, and to ascend into the nares and de- scend into the windpipe. Several soldiers of a militia regiment, stationed at Woolwich, were daily brought into the general hospital with scar- The disease was unusually fatal. Om latina. LARYNGITIS. 105 of these patients, who had been only a few hours in the hospital, died after symptoms which the Surgeon on duty thought proper to investigate by dissection. He cut out the trachea, and found it lined with a membrane as in croup. The prepa- ration was preserved, and afterwards presented to the writer of this article by his late friend Dr. Rollo, surgeon-general to the artillery: an en- graving of it was given by the writer in his work on the " Pathology of the Membrane of the La- rynx." At page 37 of the same work, will be found an account of two cases of inflammation of the larynx, one occurring about the eighth or ninth day of fever in a girl eight years of age, who was relieved by bleeding; the other in a girl of eleven, in whom an attack of bilious remittent fever was ushered in by laryngeal inflammation. A fatal case of laryngitis occurring during appa- rent convalescence from remittent fever, published in the first volume of the Transactions of the Physico-Medical Society of New York, was re- published in the Medico-Chirurgical Review for April, 1827. In erysipelas the fauces are often inflamed, and the inflammation extends to the larynx, in which case the respiration resembles that of croup, and the disease is generally fatal. A female thirty- four years of age, had been in the hospital at Cochin for disease of the heart, when, on the 23d of February, she was seized with violent rigor; 24th, erysipelatous eruption of the face with fe- brile re-action; 25th, 26th, the erysipelas was extended to the hairy scalp and to the neck, eyes closed; 27th, acute pain in the throat, difficult deglutition, respiration impeded; 28th, swelling and inflammation in the anterior part of the throat; inability to expectorate; suffocation threat- ened. March 1st, swelling of the neck enormous —asphy x ia—death. Dissection^— The mucous membrane lining the mouth, larynx, and pharynx, red and inflamed. The epiglottis and its ligaments thickened; the lima glottidis nearly annihilated by the swelling and by tough mucus. The cellular tissue of the larynx, face and neck injected, red, and oedema- tous; the lungs sound. (Bouillaud.) 4thly. The larynx is often inflamed in those diseases in which the inflammation extends over the whole of the mucous membrane of the lungs. In common and also in epidemic bronchitis, the inflammation, apparently commencing in the Schneiderian membrane and fauces, often affects the larynx in its descent into the bronchi. The membrane of the larynx is also liable to be af- fected in those varieties of chronic bronchitis, which, according to the season or age at which they occur, or according to the symptoms of the attack, have been termed winter cough, catarrhus senilis, suffocative catarrh, or peripneumonia notha. In pertussis, inflammation often obtains in the mucous membrane of the larynx as well as in that of the trachea and bronchi. Lastly, in croup, the symptoms referable to inflammation of the larynx are so obvious and remarkable as to have exclusively engrossed the attention of most observers, leading them to overlook proofs, scarcely !ess equivocal, of an inflamed condition of the bronchi. 5thly. We have known many cases of inflam- Vol.HL—14 mation of the glottis arising from an accident, to which the children of the poor are liable. Slat- ternly mothers often permit their children to drink from the spout of the tea-kettle, and the children are thus led to a habit which, if the kettle should happen to contain boiling water, may prove fatal. The symptoms produced by this accident are in- flammation and vesication of the fauces, difficult breathing, audible inspiration, whispering voice, leaden countenance, watery eyes, and cold ex- tremities— symptoms which we were wont to think were as much dependent upon bronchitis as upon inflammation of the glottis ; but a dissection published by Dr. Marshall Hall, in his satisfactory account of this affection in the twelfth volume of the Medico-Chirurgical Transactions, would lead to a conclusion that the inflammation does not extend even to the trachea. We have been ac- customed to treat this affection by bleeding, blis- tering, and a preparation of calomel and ipecacu- anha. Our confidence in bleeding is not, how- ever, very great. The children soon acquire that peculiar expression which livid paleness with oedema imparts, when asphyxia, in an advanced state of bronchitic inflammation, is impending, a state which contra-indicates free bleeding. Bron- chotomy is recommended by Dr. M. Hall, and this operation his view of the case would amply justify. He also recommends scarifying the epiglottis. Probably small doses of opium, given at an in- terval of two or three hours, would be useful, as they generally are in burns attended with much suffering. In the third volume of the Dublin Hospital Reports there is a case given by Dr. Burgess, of a girl of three years of age, who drank boiling water from the pipe of a tea-kettle, by which great swelling of the parts immediately ensued, thereby preventing deglutition and impe- ding respiration. In about two hours after the accident, in looking into the mouth, it appeared as if a large piece of raw flesh had been forced into the fauces, and had completely filled up the passage. Respiration was performed with very great difficulty, and was rapidly becoming more laborious,—in fact the child appeared to be dying, when bronchotomy was performed, by which life was saved. 6thly. Inflammation of the mucous membrane of the larynx sometimes arises when the system is under the influence of mercury. We think we have seen inflammation extending to'the wind- pipe in severe cases of mercurial glossitis, and hence we are unwilling to reject, as one of the species of laryngitis, that caused by mercury. But we are not satisfied that the cases of alleged mer- curial laryngitis, which have been recently pub- lished, did not owe their origin to other influences, such as lues venerea, or exposure to cold, rather than to the mercury. 7thly and Sthly. There are yet two inflamma- tory affections of the membrane lining the larynx which must be briefly described, in order to com- plete this part of the subject: these are scrofulous inflammation of that portion of the mucous mem- brane, and inflammation symptomatic of secondary syphilis. Scrofulous inflammation is an affection of a very dangerous nature, not, as we apprehend, generally accompanied with tuberculated lungs. 106 LARYNGITIS. This affection is not confined to youth or adoles- cence ; sometimes it appears at or after the me- ridian of life, as the commencement of a very chronic variety of phthisis, which some physicians have imagined depends upon indigestion, and is to be cured by blue pill, &c. We have frequently witnessed this affection in an acute form in per- sons who had abandoned themselves to the habit- ual use of ardent spirits, in muddlers, as they are called, who drink at all times, but seldom to com- plete intoxication. Such patients lose their appe- tite ; become emaciated ; usually have a patchy purplish complexion; gradually acquire a dry hard cough, which at first appears nothing more than an aggravation of that cough observable in drunkards, which is attended with white and scanty expectoration, and is followed, especially in the morning, by retching or even vomiting of a little clear ropy fluid. If we examine these pa- tients, we shall find the pulse accelerated, the tongue and fauces florid, the former glazed. This disease is always fatal, but generally not until purulent expectoration, colliquative diarrhoea, and night sweats, have existed for some time. It often is to be met with in publicans, and such as are engaged in the occupation of vending ardent spirits. It is attended with a sense of exhaustion, a depression of mind, a fear of death, and a con- sciousness of the disease being self-produced, which it is most painful to witness. The patient may, in the commencement, derive some advantage from change of air, exercise on horseback, very small topical bleedings, not more than three or four leeches being applied, followed by counter-irritants and light bitters. The bowels must be properly regulated, avoiding all medicines which lower the strength ; and a mild alterative pill may be given for ten days or a fortnight, namely, R Pilulrn hydrargyri, scrupulum. Pulveris conii, scrup. ii. Ipecacuanha?, gr. xv. Ammoniaci contriti, sesquidrachmam, M. et di- vide in pilulas xl. Sumat duas mane et meridie ; superbibendo poculum lactis asinini. Milk, shell-fish, broiled, tender but lean meat, and vegetable jellies will form the most suitable nourishment. The more common form of scrofulous inflam- mation of the larynx and trachea belongs to youth, and occurs in those families of which the members are liable to consumption. It has seemed to us often to arise from night-air and fatigue, es- pecially when these causes operate during a sea- son of mental anxiety and over-exertion. This is a frequent disease with those wretched females who frequent the streets of our cities in the night, and their obscene haunts during the day. The hue which may be observed on their cheeks is not always the glow of intemperance or of shame, nor yet the factitious blush of effrontery, but is often the crimson of a consuming hectic, which is ra- pidly hurrying them from misery to misery. It is little known how large a portion of the tenants of the brothel actually labour under consumption : but the subject is too horrible to be pursued. At first the disease is attended with a dry bark- ing cough, a single bark, often supposed to be a stomach cough ; but the symptom which is most distinctive of this very treacherous complaint, and which in consumptive families ought ever to exeii, the liveliest apprehension of danger, is a change in the sound of the voice, which the patient caj no longer extend without difficulty. It is slightly raucous, and acquires that hollowness which, both as if proceeding from a vault and in reference to its tendency, is not unaptly called sepulchral When, the attention being arrested by the cough and the sound of the voice, which often have ex- isted for many weeks or even months before they become objects of regard, we more closely examine the patient, we shall find that there is some un- easiness in the region of the larynx, or in the su- perior part of the thorax ; a degree of quickness of the pulse is discoverable, as also some emacia- tion and decay of the strength, but the latter so slight as to have escaped notice. Indeed so insi- •dious is this disease, that in many instances it hu passed undiscovered until some acquaintance, who had not for a considerable time seen the patient, discerning a great change in his looks, expresses his apprehension. Then the truth, in all its na- kedness, flashes on his alarmed relatives, and t physician is obtained who detects the nature of the disease by discovering that there are irregular chills followed by heats and perspirations, and confirms all their fears. The patient soon loses the power of extending his voice; he can only speak in a whisper ; his cough becomes stridulous, his expectoration purulent, and laryngeal or tra- cheal consumption is incurably established. If t patient, fortunately for himself, should in the com- mencement of his disease be visited by a person possessed of medical skill, his life may sometimes be saved. In the treatment of this complaint, if the disease should not have reached the suppura- tive stage, we must disregard the diathesis, and address ourselves to the local affection. First, we must apply leeches to the upper part of the ster- num ; we prefer three or four leeches every third or fourth day to a greater number ; secondly, the tartar-emetic ointment (taking care that it does not reach the leech-bites) to the sides of the larynx, first to one side and then to another) thirdly, we must give the solution of tartar-emetic (so as to excite slight nausea) with the addition of nitre. R Antimonii tartarizata, gr. duo. Nitratis potassse, scrup. ii. Aquae distill, unc. sex: M. et divide in haustus sex. Sumat unum, ter, quatervc de die. Lastly, a diet consisting of milk, farinacea, and fruits, will be necessary. This plan may be fol- lowed for eight or ten days; if without efficacy, new measures must be tried, as change of air and scene, and restoratives, such as a return to the use of animal food, a glass or two of claret, and sponging the surface with very diluted nitro-m* riatic acid, which may also be taken internally. If the expectoration be considerable, a drachm of Riga balsam in a glass of water may be taken three times a day, or the following draught: R. Tinct. benzoini composita), 31. Mucilaginis acacias, gii. , Syrupi papav. albi, gi. Aquae cinnamomi, gvi. M, together with such treatment as would apply to impending laryngeal or tracheal phthisis. There are certain cases of scrofulous inflammts* LARYNGITIS. 107 i tion of the windpipe that are invariably overlooked , in the first stage, of which the first symptoms detected are round and pretty deep ulcers in the fauces. The affection of the larynx so commen- cing, according to our observation, always ends in > phthisis. The syphilitic inflammation of the larynx, like the last variety, is seldom discovered in its very beginning. This disease is introduced by anoma- lous symptoms of constitutional disorder, and an ,, obscure febrile state. The patient's expression appears altered and anxious, his complexion pale or mixed, his skin opaque and, as it were, dirty, ; his eyes hollow, the tarsi slightly inflamed; some degree of emaojation takes place ; then the voice becomes husky. These symptoms will naturally suggest that line of inquiry which we adopt when we are endeavouring to detect a syphilitic taint; and here it will not be irrelevant to observe that a change in the sound of the voice, whenever it ac- companies a cachectic state of the body, demands the utmost attention,—attention which will some- times be rewarded by enabling us to discover the approach of a disease that would shortly assume a hopeless expression. In syphilitic inflammation of the larynx, when the head is suddenly turned to a side, uneasiness will be felt in the organ, which, when pressed, feels tender. The patient suffers much from a stridulous cough, attended • with little or no expectoration. These symptoms •'■ being neglected, ulceration of the membrane of :'J the larynx next ensues, which may be discovered by difficult and suffocative inspiration and cough, * by purulent expectoration, and by unequivocal hectic, attended with great irritability of the ner- vous system, and, lastly, by permanent loss of - voice. In the commencement of this affection, •' we must endeavour to subdue the inflammation ' by means of leeches, blisters, and the antiphlogis- tic regimen. Then we must give the muriate of mercury in decoction of sarsaparilla, and employ mercurial fumigations. In this manner, with the help of change of air, . a remedy often of surprising efficacy in specific v inflammations, a cure may sometimes be accom- : plished ; but syphilitic inflammation of the larynx, which we apprehend will be most likely to occur in strumous habits, will, in general, like the pro- per scrofulous inflammation, terminate in laryn- - geal consumption, unless a termination should take place in the inflammatory stage, such as was c, exemplified in one of Bouillaud's patients, who died of suffocation so early as the fifth day, the ,; cellular membrane being so thickened, infiltrated, and gorged, as almost to obliterate the rima glot- tidis; and on the left side of the larynx an ulcera- tion being formed with the characters of chancre. , (Med. Chir. Journ. for July, 1825, p. 206.) When , syphilitic ulcers exist, they will generally be found in the sacculi laryngis. We have, in a specimen of diseased larynx, seen fimbriated excrescences in the glottis, which were probably syphilitic, but we were not able to obtain a history of the prepa- ration. As we learn from an ably written paper by the late Mr. Wood, in the seventeenth volume of the Medico-Chirurgical Transactions, on the effects of inflammation of the larynx, that a patient , lately died in St. Bartholomew's Hospital, of a disease of the larynx, which was discovered after death to be cancerous; and as Dr. Monro, in the 2d volume of his Outlines of Anatomy, informs us that he has seen in some cases the arytenoid and thyroid cartilages thickened and covered by a scirrhous substance, by which the glottis was straitened; it is probable that our successors in pathology, when facts accumulate, will add a ninth species, viz. scirrhous inflammation of the larynx, to the foregoing catalogue of diseases of that organ. We proceed to the consideration of laryngitis, which is a more suitable designation for the dis- ease now under review, than angina ceo'ematosa, as applied to it by some authors: it has been well observed that " the term oedematosa is unneces- sary, as oedema constitutes no fundamental cha- racter of laryngitis, but is an effort or consequence of inflammation of the affected organ," (Med. Chir. Journal for July, 1825, p. 206,) in what manner soever excited. Of laryngitis, it is true, notices and cases were previously published, but the disease was not generally understood prior to the publication, by Dr. Farre, of a valuable paper on cynanche laryn- gea, in the third volume of the Medico-Chirurgi- cal Transactions. Our knowledge will often be advanced by examining a specimen of a disease before we apply ourselves to the study of its general history. We therefore beg to call the attention of the read- er to a case of laryngitis in every way interest- ing, but especially so to the pathologist, as being the first accurately reported history of that disease which, as far as we know, is to be found in the annals of medicine. " Some time on the night of Friday, the 10th December, 1799, having been exposed to rain on the preceding day, General Washington was at- tacked with an inflammatory affection of the upper part of the windpipe, called in technical language cynanche trachealis. The disease com- menced with a violent ague, accompanied with some pain in the upper and fore part of the throat, a sense of stricture in the same part, a cough, and a difficult rather than a painful deglutition, which were soon succeeded by fever and a quick and laborious respiration. The necessity of blood- letting suggesting itself to the General, he pro- cured a bleeder in the neighbourhood, who took from his arm in the night, twelve or fourteen ounces of blood. He could not by any means be prevailed on by the family to send for the attend- ing physician till the following morning, who ar- rived at Mount Vernon at about eleven o'clock on Saturday. Discovering the case to be highly alarming, and foreseeing the fatal tendency of the disease, two consulting physicians were immedi- ately sent for, who arrived, one at half after three, and the other at four o'clock in the afternoon. In the mean time were employed two pretty copious bleedings, a blister was applied to the part affected, two moderate doses of calomel were given, and an injection was administered, which operated on the lower intestines; but all without any perceptible advantage, the respiration becom- ing still more difficult and distressing. Upon the arrival of the first of the consulting physicians, 108 LARYNGITIS. it was agreed, as there were yet no signs of accu- mulation in the bronchial vessels of the lungs, to try the result of another bleeding, when about thirty-two ounces of blood were drawn, without the smallest apparent alleviation of the disease. Vapours of vinegar and water were frequently inhaled ; ten grains of calomel were given, suc- ceeded by repeated doses of emetic-tartar, amount- in? in all to five or six grains, with no other effect than a copious discharge from the bowels. The powers of life seemed now manifestly yielding to the force of the disorder; blisters were applied to the extremities, together with a cataplasm of bran and vinegar to the throat. Speaking, which was painful from the beginning, now became almost impracticable; respiration grew more and more contracted and imperfect, till half after eleven on Saturday night, retaining the full possession of his intellect, when he expired without a struggle. He was fully impressed at the beginning of his complaint, as well as through every succeeding stage of it, that its conclusion would be mortal; submitting to the several exertions made for his recovery, rather as a duty than from any expecta- tion of their efficacy. He considered the opera- tions of death upon his system as coeval with the disease; and several hours before his death, after repeated efforts to be understood, succeeded in expressing a desire that he might be permitted to die without further interruption. During the short period of his illness, he economized his time, in the arrangement of such few concerns as required his attention, with the utmost serenity; and anticipated his approaching dissolution with every demonstration of that equanimity for which his whole life had been so uniformly conspi- cuous."* The violent ague with which this case com- menced was doubtless the rigor of incipient in- flammation ; the. pain in the upper and fore part of the throat, the sense of stricture in the same part, and the labour of respiration, showed that inflammation was seated in the larynx. The dif- ficult deglutition arose from the state of the tonsils, in which probably the inflammation commenced. The inflammation did not descend into the bron- chial vessels of the lungs, wherein we are told there were no signs of accumulation. It may be inferred, therefore, as will be apparent from the sequel, that this was a genuine specimen of laryn- gitis. Laryngitis generally arises from exposure of the body, or a part of it, to cold or wet, or from sudden transitions of temperature. It affects those persons who are liable to cynanche tonsillaris, and often commences as one of their accustomed at- tacks ; and hence the patients arc seldom alive to danger until a feeling of suffocation convinces them that their illness is one of unusual severity. In the Richmond Surgical Hospital, House of In- dustry, Dublin, we saw a case of inflammation of the larynx, which commenced in the tonsils, and was by malpractice extended to the larynx. The patient was a robust young man; his face was much flushed, his pulse quick. He was com- pletely hydrophobiac. When he tried to swallow, * This account is dated Alexandria, Vir.. Dec. 21,1799, and signed by Dr. JamesCraik, attending physician, and Dr. Eli&ha E. Dick, consulting physician. the effort was followed by extraordinary difficulty of inspiration, and every attempt to articulate was productive of a sense of strangling. Then were pain and great tenderness on pressure on either side of the pomum Adami. He was at- tacked, two days before he entered the hospital, with cynanche tonsillaris, when an old woman, partial to stimulants, as such practitioners gene- rally are, rubbed the inflamed tonsils with pepper and salt, and immediately difficult deglutition came on, which was followed by constriction of the glottis. He fell under the care of an excel- lent surgeon, the late Mr. Todd, who soon re- stored him to health by copious general and local bleeding. *> If, when the throat first becomes sore, the pa- tient is examined, probably the uvula will appear inflamed, and the tonsils and arch of the soft pa- late redder than natural; and in some few in- stances exudations of coagulable lymph will be seen on those parts; the tongue perhaps is swell- ed ; the face flushed ; the pulse frequent, full, and hard; and the skin hot. The breathing soon becomes affected; the inspiration " is long in being completed," audible, and as if the air were drawn through a dry and narrow reed; the patient points to the larynx as the seat of uneasiness; he frequently coughs, and the cough is very peculiar in sound, not so ringing as that of croup, but harsher and more stridulous, and attended with scanty, viscid, and transparent expectoration. Pain is sometimes complained of in the chest. The voice, at first acute and piping, gradually becomes thick, then hoarse and whispering, anil at last it is completely suppressed. There is sometimes great difficulty in swallowing, from the epiglottis ceasing to perform its valvular office, whence it happens that, when the patient begin to drink, a portion of the fluid escapes into the larynx, and produces a fit of coughing, which seems to threaten instant suffocation. Laborious respiration and an inadequate supply of air before long affect the appearance of the patient. His expression becomes full of anxiety; his countenance pallid ; his lips leaden ; his eyes protruded and watery ; his pulse is quick, feebler, and less uniform ; and the surface of his body colder. Sometimes the integuments which sur- round the larynx, especially in the fore part of the neck, are swollen. In a case operated upon by Mr. Macnamara of Dublin, the trachea was laid bare at a depth of two inches and a half below the surface, to such an extent had the integu- ments of the neck become cedematous. The pa- tient is restless and apprehensive, often changing his position, in the vain hope of obtaining relief; walking or rather staggering to and fro, or from one room to another, in great distress : feeline. that he is on the point of suffocation, he cannot be ignorant of the danger to which he is exposed; hence he is willing to submit to any means of re- bel, and is impatient of delay. In this stage of the complaint the patient sel- dom sleeps for many minutes at a time; when he begins to doze, he starts, up in a state of the utmost agitation, gasping for breath, every muscle bein? brought into action which can assist respiration, now a convulsive struggle. He is quite enfeebled, becomes delirious, drowsy, and at last comatoH, LARYNGITIS. 109 the circulation being more and more languid, and he dies on the fourth or fifth day of the disease, or even earlier. Instances have come to our know- ledge in which the disease has terminated fatally within twelve hours, (one of Dr. Armstrong's patients died in eight hours, and another in seven ;) and therefore, if a person dies suddenly in the night, who had complained on the foregoing day of sore throat, laryngitis may be suspected as the cause of his death. Instances have also come under our observation, in which the disease has lasted three or four weeks, of which the following case is an example. We have inserted the first recorded case of la- ryngitis, that of General Washington ; and we beg to insert the first case of the disease recorded as such.* In so doing, the reader will obtain a glimpse of the second Monro, who, at a time wlien the most eminent of his contemporaries in England were ignorant of its existence, perfectly understood and explained to the writer of this article the nature of laryngitis. Mr. A. set. forty-three, robust and corpulent, in the spring and summer of 1805 was for three months under a mercurial course for secondary symptoms of syphilis. In spring 1806, he was affected with fever and pains in his limbs. In July 1806, he laid aside his flannel shirt, and thought he caught cold. July 10th, severe fits of coughing in the night; 11th, 12th, 13th, troublesome nights from the cough. V. S. ad ^xvi. 14th to 19th, emetic, squills, opiates; 20th, respiration not quickened, but difficult, constriction felt in the larynx; long-continued fits of stridulous cough; tongue white and swelled; pulse 120; by an ef- fort he can completely inflate the lungs without raising a cough. On this day the patient was first seen by the writer of the case, at whose request Dr. Monro was called into consultation, whose opinion was that the symptoms arose from in- flammation and thickening of the mucous mem- brane of the windpipe. Twelve leeches to the left of the windpipe, and a blister to the right, pulv. jalapre comp. ^ss. calomelanos gr. v. July 22d, during the night he slept not many minutes at a * Abridged from the Pathology of the Larynx and Bronchi;., by J. Cheyne, M. D. E tin. 1809. Mav we be permitted to introduce Dr. Monro to the student of pathology as a physician worthy of the closest imitation, in his writings we have somewhat too much of the ardour of controversy, into which he was betrayed in support of his reputation as a physiologist, ungene- rously assailed ; but in the common intercourse of pro- fessional life he was scrupulously correct in conduct, and in his manners urbane, lie was a strict economist of time,—a man of industry and order. His mind was un- ceasingly occupied in the acquisition of knowledge, so that no allurement, not even the pleasure of his garden, for winch he had a genuine relish, was permitted to se- duce him from his daily task of recording the results of his observation, by carefully arranging and registering the facts which he judiciously collected; and hence, after he had passed the common period of life, when between his seventieth and eightieth year, he was still to be found in his study, with hiscase-book before him, adding to his stock of pathological knowledge. In the investigation of disease he could not be viewed without admiration. His digested experience, his keen observation, and the excellent method of inquiry which he pursued, rendered him a personification of medical sagacity, and enabled hnn, tu consultation, to tower above the great competi- tors of his youth and age, the one a man of genius, the other of talent—Cullen and Gregory, who were children compared with Monro in the power of discovering the nature and predicting the course of an obscure and un- common disease. He was remarkable for the possession of tact, employing the term not merely as expressive of discrimination, but also of lhat quality which, in the time ; cough threatening suffocation; expectora- tion of clear ropy mucus; hissing inspiration ; tongue furred and swelled ; evident fulness as well as tenderness on the left side, and in front of the thyroid cartilage, which is painful when the head is turned. When in bed his head is low, and thrown to the left side ; when sitting, his chin is projected; countenance anxious. Opinion : as the disease appears to be confined to the upper part of the windpipe, it was resolved, should suffocation be imminent, to perforate the larynx between the thyroid and cricoid cartilages.— Leeches, blister, steam of warm water and vinegar. July 24th, miserable nights; often on the point of suffocation ; pain on pressure in every part of the trachea, pulse 128; tongue more swelled. July 27th, in the last three days a pound of blood was drawn each day. The first blood sizy and cupped. Laudanum produced sleep, but he awoke gasping, dyspnoea being then more severe. Some- times he started from his chair, and staggered from one room to another; then his face was quite livid; his pulse, an hour after a paroxysm, was 136. Tongue swelled, and indented from the impression of the teeth. Emetic of ipecacuanha proved nearly fatal. When he began to vomit, his inspi- ration was intenupted and crowing; his face was pale, and his lips livid. Gr. ii. calomelanos ter quotidie. Evening, haflstus cum tinct. opii et vini ant. gutt. x. August 4th, sickness after the eve- ning draught, which lasted all night. At 7 a. m. breathed with great difficulty; extreme cold. He was taken out of bed and seated on a sofa, sup- ported with cushions and pillows, after which his head fell upon his breast, and he ceased to respire. When his head was raised, respiration was re- sumed, but it was stertorous, and his complexion was changed from the purple of imperfect respira- ration to the paleness of a cadaver. Bronchotomy was performed without effect; he died in about two hours after the operation. We were not per- mitted to examine the body, but concluded that death arose from closure of the rima glottidis, owing to thickening of its lining membrane. At one time it was conjectured that this case exploration of diseases in the thorax, abdomen, and pel- vis, enables the physician, by manual examination, to detect the nature of the altered structure of the organs contained in these cavities. Monro, in his inquiries, brought not merely his touch, but all his senses to his aid in an extraordinary manner Long before the time of l.aennec he availed himself of the aid of auscultation (immediate, in ascertaining the existence and nature of diseased conditions of the heart. We have known him sit for a long time, with his ear applied to the thorax, deriving information from a mode of inquiry at that lime peculiar to himself. Finally, though remarkable for caution, he possessed great decision of character, of which his practice, never rash, but often extremely bold, afforded sulrkient evidence. The therapeutic agents winch he employed were skilfully combined, und while mere effect was despised by him, while " His vigorous remedy displayed The power of art without the show"— nothing was omitted in weak compliance with the pre- judices of his palient. This sketch will be pardoned by all those who think that, even with advancing age, there ought to be no abatement of zeal in the cultivation of professional science; that improvement in all things is promoted by placing models of excellence before the eyes of the student; and that an expression of gratitude is seemly. The writer, tia ving d.-n ved many useful lesson* from studying the character of Monro, has never lost an opportunity of paying an humble tribute to his memory. It appears surprising that this «reat pathologist should have been allowed to retire from the theatre of his use- fulness without receiving one valedictory plaudit. 110 LARYNGITIS. was connected with syphilis; but if such a com- plication had existed, it is probable that the inflam- mation would, in four weeks, have reached the ulcerative stage, of which the expectoration afforded no evidence. This case, with several others which fell under our care, induced us to attempt a defini- tion of the disease in the following terms. " Pain in the larynx not very acute, unless on pressure ; some degree of fulness externally; a change in the sound of the voice, difficult and even crowing inspiration, but slow rather than quick ; an altered, sometimes stridulous voice; fits of suffocative coughing; and all those symptoms which arise from obstructed circulation in the lungs." (Vide Pathology of the Larynx, p. 161.) Causes.—Persons advanced in life are more liable to laryngitis than the youthful; and of the former the disease most frequently occurs in such as are liable to indigestion, connected with a dis- ordered condition of the liver. Several of our patients had been habitually intemperate. The exciting causes of laryngitis, as we have already mentioned, are such as usually are productive of common cynanche or catarrh, the principal being exposure to cold. Prognosis*—In some new cases of laryngitis the inflammation recedes, and the disease termi- nates favourably. This favourable change we may presume is taking place when we discover that the swelling of the epiglottis is subsiding, that the difficulty of breathing and pain of the larynx are abating, and when freedom of expecto- ration is restored, and deglutition becomes easy. On the other hand, the danger increases with an increasing struggle of breathing. Paleness and lividity of the complexion, a prominent watery eye, and lethargy or stupor, are symptoms which indicate great urgency of danger. It may fairly be affirmed that laryngitis is the most fatal of the phlegmasia?; consequently the prognosis, in every stage of the disease, must be delivered with the utmost caution. " Of seventeen cases of laryngeal angina observed by Bayle during six years, only one ended favourably." Diagnosis. — The diseases which are most liable to be mistaken for laryngitis are— 1. Ossifications and caries of the cartilages of the larynx. This state of these bodies gives rise to extensive ulceration, of which the diseased car- tilage is the centre. This affection is often of slow growth, beginning with uneasiness in the region of the larynx, followed by hoarseness; then occur cough, difficulty of breathinrr, which is croaking, sibilous, and in paroxysms; and difficulty of swallowing; purulent expectoration, which is often of extraordinary fetor; sometimes diseased portions of cartilage on which the fetor depends, being ex- pectorated. We learn from Dr. Monro's Outlines of Anatomy, that the cartilages of the larynx, especially the thyroid, and sometimes even those of the trachea, are occasionally found ossified. In examining the body of an old man, who for the last six years of his life had been subject to a se- vere and almost unremitting cough, «I found " says Dr. Monro, " the cartilages of the larynx os- sified, a considerable quantity of viscid mucus within the trachea, and its internal coat thickened, spongy, and red. In such cases the mobility of the different component parts of the larynx being lessened or destroyed, the voice becomes much feebler; and there have been instances, as I have been informed by my father, of these morbid ossi- fications exfoliating internally, and portions of the bony matter expelled by coughing." By a patient labouring under disease of the cartilages of the larynx, who was under the care of Dr. Colics of Dublin, one of the arytenoid cartilages was ex- pectorated ; and Dr. Hunter, as we learn from Dr. Baillie, "knew an instance in which the cricoid being converted into bone was separated by exfo- liation, and afterwards coughed up." Abscesses thus formed sometimes burst into the oesophagus, sometimes into the cavity of the windpipe, and sometimes they open externally. When the pa- tient escapes sudden suffocation, this disease, which admits of treatment similar to that of simple la- ryngitis, usually ends in hectic fever. In general it is not attended with inflammation of the epi- glottis, and instead of terminating within four or five days, its course is tardy. To this disease, rather than to simple laryngitis, we apprehend belonged thecase of the Right Hon. Isaac Corry, as detailed by the late amiable and accomplished Dr. Edward Percival, in the fourth volume of the Medico-Chirurgical Transactions. In Mr. Cony's case, as we learn from Dr. Colles, who was one of his attendants, the epiglottis was in a natural state, and the rima glottidis little if at all reduced in its capacity. Of the same nature appears to have been the first of Mr. Lawrence's cases, pub- lished in the sixth volume of the Medico-Chirur- gical Transactions, and the case furnished by Dr, Latham, and published in the same paper,in which, on dissection, there were found two distinct ulce- rations through the substance of the thyroid carti- lage, which contained pus. Mr. Goodeve's case, published in the London Medical Journal, July, 1825, was probably of the same nature, as the patient's voice and respiration improved after the expulsion of a piece of bone from the glottis. 2. Abscesses in the vicinity of the windpipe, compressing that tube, are sometimes formed in the neck, under the fascia, and are discoverable hy hardness, swelling, and pain on pressure, oedema, and inability to open the mouth widely ; they are often accompanied with fever of a typhoid nature, which we have more than once considered as the primitive disease ;* but as, by an incision, relief may occasionally be obtained, the treatment chiefly belongs to surgery. The usual situation of these abscesses, according to Mr. Porter, is behind the broad portion of the cricoid cartilage, where it presses on the rima glottidis. The progress of this disease is sometimes rapid ; sometimes the abscess bursts behind the rima glottidis, and hectic ensues. 3. It will be necessary to recollect that aneu- nsmal tumours have given rise to symptoms re- sembling those of laryngitis, of which there is an example in Mr. Lawrence's paper. We learn from that eminent surgeon, that a patient laboured under great difficulty of drawinff air into the chest, coming on m fi^wjricjiJVL^Lawrence supposed lat'ellwDr11 T^l •"* ^J""1* ^taTas in a case re- cence from f I \eedn' "l,u:h "cc"rre 3^.. LARYNGITIS. 113 evening, gxvi. 20th Nov. gxvi. 22d Nov. guii.—Total, ^clii. For three or four days after, the patient was still in a precarious condition, and required a repetition of the bloodletting. Other cases are published, in which the lancet was successfully employed : in one of these, to be found in the sixth volume of the Medico-Chirur- gical Transactions, viz., that of Sir J. Macnamara Hayes, as reported by Dr. Roberts, of Bishop Stratford, we learn that the first bleeding » was attended with considerable relief," the second « with manifest advantage ;" by the third, " his safety appeared to be ensured." In the case of a young woman who earned a pittance by gathering cockles on the strand at ebb-tide, and afterwards hawking them through the streets of Dublin, who, on the 13th of July, 1813, presented herself at the county of Dublin Infirmary, on the second day of laryngitis, pale, scarcely able to articulate or swallow : the effort producing a convulsion as when a crumb enters the wind-pipe, the voice sounding as if she were throttled,—inspiration being slower than natural and sibilous,—the fol- lowing treatment proved successful. At noon, she was bled ad deliquium, which, by the way, had nearly proved fatal. The venesection was repeated twice in the course of the evening. On the fol- lowing day, respiration was rendered difficult by the least exertion ; hitherto unable to swallow. She was again bled, and a purgative enema and blister prescribed. Next day she began to expec- torate yellow mucus, and could swallow fluids. On the 16th July, convalescent. It is observable that the lividity of complexion which, especially in the more advanced stages of laryngitis, arises from imperfect arterialization of the blood, did not exist in any of these cases. On the other hand, bloodletting has been un- successfully practised in laryngitis, not only in the case of General Washington, but also in many others. In the second attack of laryngitis, that to which Sir John Hayes fell a victim, he was three times bled from the arm on the second day of his illness ; and the result of his case, and the other cases reported hy Dr. Baillie, in which also blood- letting was practised, led Dr. Baillie to affirm that " venesection, even when employed strenuously and early, was of no real use." But the most remarkable instance of the inefficacy of bloodlet- ting may be found in Dr. Armstrong's Practical Illustrations of Typhous Fever, p. 393. The loss of one hundred and sixty ounces of blood within six hours, gave temporary respite to the difficulty of breathing, yet was so far from arrest- ing the inflammation, that death took place within twenty-four hours. As, then, there are cases in which bloodletting is salutary, and cases in which it is hurtful, let us try to ascertain when and to what extent that remedy ought to be practised; and let us be permitted to premise that cases will occur in which it may be difficult to come to a satisfactory conclusion with respect to bloodletting —in which the considerations for and against that remedy will be balanced, so as to make the most skilful and experienced physician pause. In such a dilemma, however, it will be well that the phy- sician should not allow his doubts to transpire ; as doubts which may be the result of an accurate weighing of indications against contra-indications, Vol. III.—15 k* and which prove that he is a pathologist, will, perhaps, by the world and by his unreflecting brethren, be thought to proceed from inexperience and perplexity. We conclude, first, that bloodletting will be more clearly indicated in youth than in age. It may be observed that the same means by which Sir John Hayes was relieved during his first attack, which took place in the meridian of life, failed fifteen years after :—and, secondly, that we may bleed with most hopes of success, when the symptoms of inflammatory fever are most evident. In Sir John Hayes, during the first attack, the face was swollen and flushed ; the eyes were pro- truding and bloodshot; there was fulness about the neck, the muscles feeling very turgid, and the breast being suffused with a purplish colour; whereas, in the second attack, we find that his skin was not hot, nor his pulse more frequent than in health. " At the beginning of the attack, it may be ad- visable," says Dr. Baillie, " to take as much blood at once as to produce fainting. We beg to submit to the reader, that blood in laryngitis is sometimes so imperfect a stimulus to the heart, that if the action of that organ is interrupted, it is not improbable that it will never be resumed. In certain conditions of the circulation in this disease, I have found bloodletting a very dangerous mea- sure. 1 think it was fatal to a patient who came to the County of Dublin Infirmary about twenty years ago, when I was one of the physicians to that hospital. By my orders he was let blood, not till he fainted, but till he became pale and fainty; very shortly after the operation, which sensibly reduced his strength, he was seized, upon slightly exerting himself, with a paroxysm of difficult breathing, not more violent than many from which he had emerged, during the two or three previous days, and expired." In Dr. Beck's paper, already referred to, we learn that Dr. Hoffmann of the United States Navy was called to a patient in laryngitis whose countenance was anxious, flushed, and covered with sweat; eyes staring, and dys- pnoea insufferable ; that a vein was opened in each arm, which bled freely, and that death took place in a few minutes after. Mr. Porter, in the eleventh volume of the Medico-Chirurgical Transactions, after drawing a very lively and accurate portrait of laryngitis in a man about thirty years of age, who came to the Meath Hospital with his face pale and swollen, his lips livid, his mouth closed, his nostrils widely extended, his eyes protruded and starting from their sockets, but at the same time with the conjunctiva very white, and covered with a watery suffusion, and with an expression of indescribable anxiety; his pulse hurried, and his breathing very laborious, making two or three, or even more attempts at inspiration for one expi- ration, and his convulsive struggles for breath truly painful to behold, breathing with a hissing or whistling sound, while the utmost endeavour at speech was only an indistinct whisper;—tells us that he ordered from thirty to forty ounces of blood to be taken from both arms, and adds that in about two hours afterwards, when he returned to the hospital to perform bronchotomy, there was scarcely a pulse to be felt at the wrist; the ex- tremities were cold; the patient lay on his back 114 LARYNGITIS. almost insensible, and seemed sinking with amaz- ing rapidity. Knowing the candour of the intel- ligent and skilful reporter of this case, we are not afraid to observe that this was a combination of symptoms in which bloodletting was not likely to improve the condition of the patient, for whose sufferings the proper remedy was the knife, which was afterwards successfully employed. Indeed, Mr. Porter, in his valuable remarks on the case, has affirmed that it presents a strong illustration of the inefficacy, in laryngitis, of bleeding, blis- ters, and the various internal means usually re- sorted to for the purpose of subduing inflamma- tion. We conclude, that although we may bleed in certain states of the disease so as to influence the pulse, it would be unsafe under any circum- stances to bleed usque ad deliquium. The question of bleeding may with most safety be determined by the condition of the circulating fluid. We may, with comparative safety, bleed while the complexion is good, or, in other words, so long as the quantity of atmospheric air admit- ted into the lungs is sufficient to produce that chemical change by which venous blood, in passing from the right ventricle to the left auricle, is con- verted into arterial; but when the alteration in the appearance of the patient takes place remarked in the advanced stages of the disease, which indi- cates that the blood is no longer arterialized in its passage through the lungs; when the face and lips, especially the latter, become livid, the expres- sion anxious, the eyes protruded and watery, and when these appearances are established perma- nently, we may conclude that the stricture of the glottis is of a nature not to be relieved by blood- letting, and if so, that the patient will be injured thereby. In the early stages of laryngitis, would not the application of leeches to the palate and tonsils be deserving of a trial? This question the reader will be better able to answer after he shall have read a short but valuable paper by Surgeon Ge- neral Crampton, in the third volume of the Dub- lin Hospital Reports, on the application of leeches to internal surfaces. Mr. Crampton informs us, that in no instance in which leeches have been applied to the tonsils within the first twelve hours of the attack of inflammation, has the disease pro- ceeded to suppuration. We would bleed the patient freely during the first twenty-four hours; we should be disposed to do more—so long as the complexion of the patient is good, we would have recourse to venesection, keeping a finger on the artery while the blood flows, and closing the orifice when the pulse is re- duced : we would have leeches applied, or blood removed from the nucha by cupping ; and should be disposed to bleed again, or even a third time, so as to abstract forty or fifty ounces of blood, and at the same time let the patient have a powder containing two or three grains of calomel, three or four of pulvis Jacobi veri, and one-half or one- third of a grain of opium, every third or fourth hour, till the gums become affected. This we prefer to an exhibition of tartar-emetic, not wish- ing to expose the patient to the danger of vomit- ing, which is productive of a frightful struggle in laryngitis. Blistering the neck is of very ques- tionable efficacy, and by the inflammation, stiff- ness, and soreness which it occasions, adds much to the sufferings of the patient, and, when bron- chotomy becomes necessary, to the inconveniences which attend that operation. If the physician reposes much confidence in the antiphlogistic power of a blister, let it be deferred till bleeding has been carried as far as is expedient, and then let it be applied to the upper part of the sternum. " From bleeding and opiates," says Dr. Baillie, "if no substantial advantage is produced in thirty hours, it might be advisable to perform the opera- tion of bronchotomy at the upper part of the tra- chea, just under the thyroid gland." We appre- hend, however, that a consideration of the mere duration of the disease will lead us astray; thirty hours may be too long to wait, or it may be too short. If the circumstances of the patient, espe- cially the condition of the circulating fluid, be such as to contra-indicate bleeding, and to show that asphyxia is imminent, it may be improper to put off the operation for thirty minutes. If the complexion is good, if asphyxia is not threatened, the operation may be delayed for thirty days. In Dr. Baillie's second case already referred to, it is stated, " in the night time, the patient becom- ing much worse, Mr. Tegart, who scarcely ever left him night or day, went for Mr. Home and Mr. Wilson to perform the operation of broncho- tomy. Mr. Wilson was out of town on profes- sional business, but Mr. Home came about four in the morning. The patient, however, was be- ginning to sink, so that no advantage from an operation was now to be expected." It is, indeed, probable that bronchotomy would not have saved the patient; but as that operation in an adult can be performed without difficulty, and as there are instances of its having been successful even when the brain was oppressed, which is the most alarm- ing symptom in this disease, we humbly think that no patient who is not in the article of death ought to be deprived of the chance of escape which it affords. The patient operated upon by Mr. Goodeve, surgeon to the Clifton Dispensary, was quite insensible when the operation was per- formed ; " no pulse could be found at the wrist, his face was suffused with blood and his lips livid, and it was hard to say whether he breathed U not," and yet he recovered. There can be little doubt but that in most easel the aperture ought to be made between the thyroid and cricoid cartilages, but in this matter the sur- geon must be the arbiter.* The operation hu * On this subject consult Mr. Lawrence's paper in the sixth vol. of the Medico-Chirurgical Transactions. The writer of this article many years ago reeon)' mended the introduction of a trocar and canula, with- out previous incision. This operation is justly con- demned by Mr. Wood in his valuable paper published ia the seventeenth vol. of the Medico-Chirumcal Transac- tions. Mr. Wood observes: " Dr. Cheyne has advocated an operation equally reprehensible with that of Des*aull, who recommended the introduction of an elastic tutu through the nostril into the trachea, that of introduce into tae trachea a trocar and canula without previous in- cision, the reflection that the cunula must irritate b» being moved up and down with the larynx, which does n?»i1I'.'VP '" asSOcia,,ion witn the s|t"n, combined with tne uanger of wounding a large blood-vessel irrccularin ■art, ™h',i, 5 ^optiagus a«id contiguous important parts, and the depth it may be necessary to penetVateio Krh^ of «*e unusual depth of the t?achca ftsna the surface ought to preclude this use of the trocar," &c. This quotation is introduced as an amende for U* ".consideration that led to the proposal of an operation which is so objectionable. operawu LARYNGITIS, [CHRONIC] 115 often proved perfectly successful, and a canula has been worn for a long time without much inconve- nience. Thus the patient operated upon by Mr. Goodeve wore a tube for more than six months; he was then able to lay it aside, and his voice was quite restored. In the fourth volume of the Dub- lin Hospital Reports, we learn from Mr. White that one of his patients was wearing a tube with- out being prevented from working at his trade, which was that of a cabinet-maker, two years after the operation; the sides of the opening, which was of an oval shape, and one inch in depth to the trachea, being perfectly healed, smooth, and covered with a thin cuticle. But the most remarkable proof of the relief which the canula is capable of affording, is that which is supplied by the case of Mr. Price of Portsmouth; we learn in the twenty-ninth number of the Medico-Chirurgi- cal Review, in which journal there is much valu- able information to be found on laryngitis, that Mr. Price had been breathing for about fifteen years through a canula. Laryngitis sometimes is more of a chronic than acute affection, in which case the affected organ probably undergoes a considerable change of structure; in the case in Mr. Lawrence's paper, which we have already alluded to, which conti- nued for nearly four months, the mucous mem- brane had assumed a thick and puckered condi- tion, and had partially thrown out coagulable lymph of a stringy and fimbriated texture, which obliterated the ventricles of the larynx. In one of our cases which had lasted four months, the mem- brane lining the glottis, and arytenoid cartilage, was like a thin layer of flexible cartilage. In chronic laryngitis, mutatis mutandis, the same principles of treatment are applicable as in the acute species. Bronchotomy may be necessary to prevent that fatal exhaustion arising from conti- nued disturbance of the respiratory function, as it was in the case related by Dr. M. Hall in the tenth volume of the Medico-Chirurgical Transactions; but medical means alone will often prove suffi- cient for the removal of the inflammation, if it be unaccompanied with ulceration. The remedies chiefly to be relied on in chronic succeeding acute laryngitis, are, change of air—this remedy we again specify, even at the risk of being thought to harp a little too much upon one string; — the establishment of a discharge from both sides of the larynx by means of small caustic issues ; and mild mercurials, with the infusum sarsaparillse conipo- situm of the Dublin pharmacopoeia. J. Cheyne. [Chronic Laryngitis has received more atten- tion of late years than formerly, and will, therefore, require further consideration. This term has been employed synonymously with Laryngeal phthisis, Phthisis laryngca,- whilst laryngeal phthisis it- self has been employed by MM. Trousseau and Belloq, so as to comprise " any chronic alteration of the larynx, which may bring on consumption or death in any way." It has been used, indeed, to include all chronic diseases of the larynx. In this place, the epithet " chronic" is employed in regard to laryngitis, in the same manner in which it is applied to other inflammations of mucous membranes:—to signify inflammation of the lining membrane of the larynx, or of the subjacent parts, the duration of which is long, or whose symptoms proceed slowly. Diagnosis. —The commencement of chronic inflammation of the various structures composing the larynx is often extremely insidious, and its pro- gress so tardy, that much, and often irreparable mischief is accomplished before any alarm is taken by the patient, and he applies for medical assistance. Pain is fell in the larynx, but its precise situation may vary ; at times, it extends over the larynx ; but, at others, is restricted to a small space, and generally to the region of the thyroid cartilage. Commonly, a kind of tickling sensation exists, which provokes coughing. The pain, too, is ex- asperated by coughing, speaking, and deglutition, especially when ulcerations exist, and they are situate above the ventricles of the larynx. The breathing of cold air, and pressure upon the larynx likewise augment it. The voice is almost always changed, being hoarse, and, at times, so much en- feebled, as to be inaudible. The aphonia may supervene suddenly or gradually, and ultimately be complete. Cough is a constant concomitant, and when the mucous membrane is much swollen, it becomes hoarse and even croupy. In the first instance it is dry, but subsequently it is accompa- nied with the expectoration of mucus, mixed oc- casionally with pus or blood. At other times, a membraniform matter is expectorated for months; and at others a considerable quantity of false membrane is thrown off, after which the patient rapidly recovers. Occasionally, portions of carti- lage are mixed with the mucous or bloody sputa, and in such cases, there is always accompanying hectic. Chronic laryngitis has, indeed, been di- vided into two heads ;—the first comprising that which affects the mucous membrane and the sub- mucous tissue; and the second, that which im- plicates the cartilages; the latter—it has been con- ceived—having perhaps the best claim to the name phthisis laryngea, from the incurable nature of the affection, and the hectic and emaciation, which invariably accompany its latter stages. When chronic laryngitis is slight, and there is not much narrowness, the difficulty of breathing may not be great; but if it be attended with much tumefaction of the lining membrane, the dyspnoea is considerable, and the sound, on inspiration, so- porous and peculiar. It is evidently, too, aug- mented by paroxysms. The air of inspiration likewise gives rise to a snoring (ronflement) or whistling, (sifflement,) which may be continuous, or recur in paroxysms. These local symptoms may be so slight, that the general health does not suffer to any great degree. Commonly, however, more or less sympathetic febrile disorder is appa- rent, under which nutrition is impaired, and atro- phy supervenes. The disease now merits the term Laryngeal Phthisis, which is, however, in the immense majority ofcases, connected with the presence of pulmonary tubercles. Chronic laryngitis may be primary, or it may succeed to acute laryngitis, and when apparently terminating in health, it is readily reproduced by exposure to cold, errors in diet, &c. &c. Its du- ration varies from a few months to several years. When the fauces are inspected, but little evi- dence of disease may be perceptible; at other 116 LARYNGITIS, [CHRONIC] times, however, the mucous membrane is injected, and the follicles are so large as to resemble split peas. Whether this enlargement of the follicles be the cause or effect, may admit of a question. The enlarged follicles probably exist lower down, where they cannot be inspected. This form of laryngitis is the one often known under the name « Clergymen's sore throat." Chronic laryngitis may terminate in health ; but it is more likely to end fatally; and this may occur in different modes,—either by the lungs becoming implicated, or by the extent of the laryngeal le- sions themselves, which may excite severe irritative fever, or interfere with the entrance of air into the lungs, and thus induce asphyxia. In almost all cases of phthisis laryngea, the disease is compli- cated with pulmonary tubercle. Dr. Stokes, indeed, asserts, (On Diseases of the Chest, Amer. edit., Philad. 1844,) that after ten years of hospital and private practice, he never saw a case presenting the symptoms of laryngeal cough, purulent or muco- purulent expectoration, semi-stridulous breathing, hoarseness, or aphouia, hectic, and emaciation, in which the patient did not die with cavities in his lungs. In some, the laryngeal affection seemed to be primary; but, in the great majority, symptoms of pulmonary disease existed previous to its ap- pearance. Such, also, is the result of the writer's observation. In many cases of pulmonary phthisis, — sore throat, hoarseness, or aphonia, with cough, occur; but the case is different, when the laryngeal symp- toms have been primary. Causes.—The same causes, that give rise to acute laryngitis, may induce the chronic form also. It may be caused, like the acute, by the inspira- tion of acrid substances, or by extraneous bodies received into the larynx. The habitual and in- temperate use of ardent spirits has likewise been esteemed a cause, as well as the effects of mercury. These act either as predisposing or exciting causes. It is often the result of phthisis pulmonalis; whilst, on the other hand, the pulmonary irritation, in- duced by it, may occasion the development, and augment the course of tuberculosis of the lungs in those who are predisposed to pulmonary con- sumption. The coexistence of ulceration of the lungs, and of suppuiated pulmonary tubercles, has often been proved. In one-fourth of the cases of phthisis, ulceration of the larynx has been observed; in one-sixth, ulceration of the epiglottis; and ul- ceration of the trachea was met with by M. Louis, more frequently than either of the other lesions. (On Phthisis, 2d edit., translated by Dr. Walshe —Sydenham Society edit. Lond. 1844.) It is prob ible, however, that the idiopathic chronic la- ryngitis rarely produces the symptoms of phthisis ; 4 but the two diseases are frequent concomitants. • Amongst the exciting causes are mentioned— prolonged action of the vocal organs; hence the disease is said to be frequent among actors, singers, lawyers, preachers, &c. It has already been re- marked, that it is so common among the last as to have received the name of the clergymen's sore throat,- yet why it should prevail among them more than among lawyers, professors, &c, who use their vocal organs more, is not so clear. It has, indeed, been suggested, by Professor Chap- man of Philadelphia, that clergymen, as a class, are of feebler constitutions, which circumstance may have originally led them to embrace their avocation ; and, hence, that they are more liable to such derangements than more healthy Individ- uals; but this does not seem sufficient to accorjfe for the difference. Another explanation has been offered by Dr. Stokes—(Op. «7.) that the clergy. man begins to exercise his vocal organs at a much earlier period than the lawyer, for example. The young clergyman, often of a feeble and nervous constitution, and acting under conscientious mo- lives, to the neglect of bodily health, not only reads the service, and preaches once or twice, or even more frequently in the week, but is exposed to night air and the inclemency of the weather. He is compelled to do so, while both the larynx and constitution of the lawyer have generally full time for maturity, before he need employ the one or expend the other in the duties of his profession. Syphilis would appear to be a frequent cause of chronic laryngitis, and especially of the ulcerative form,—the ulcers extending, at times, from the throat by continuity of surface. As to age, the disease has certainly been ob- served most commonly between twenty and forty; but, as to sex, discrepancy of sentiment exists ;— some, as Ryland, (On the Diseases and Injuria of the Larynx and Trachea, Amer. Med. Lib. edit. Philad. 1839,) affirming, that the number of females, attacked by it, is infinitely greater than that of males ; others, as Andral, (Cours de Pa- thologie Interne,) that males are more frequently affected than females. Pathological Characters.—Chronic inflam- mation induces the same changes in the laryngeal mucous membrane as in other membranes of the class; for example, redness, increased thickness, and alteration of consistency, over a greater or less extent of surface. Occasionally, too, vegetations of considerable size, and white and hard granula- tions are perceptible. Pus, too, is generally found covering its surface. The mucous follicles, both of the lining membrane of the pharynx and la- rynx, are frequently enlarged, especially in that form of the disease to which clergymen are sub- ject, and they seem filled with a yellowish matter. Ulcerations are likewise very common, so as even to destroy the vocal cords. The submucous cel- lular tissue is often infiltrated by a thin fluid; and, at times, collections of pus exist in it; at others, it is indurated, and tubercles are found in different stages of development. The intrinsic muscles of the larynx have been found much reduced in size, softened and occasionally destroyed. At other times, they have been hypertrophied. The epi- glottis may be thickened, ulcerated, carious, and even completely destroyed; yet the patient may have been able to swallow to the last. Of the cartilages of the larynx, the cricoid and the aryte- noid are most frequently diseased__the thyroid least so. Occasionally, they are ossified, or ossific points are deposited on the mucous membrane. la broken down constitutions, in which large quanti- ties of mercury have been used, it has been re- marked, by Drs. Graves and Stokes, that chronic laryngitis is very apt to terminate in ulceration of the cartilages. Treatment. —In the treatment of chronic i laryngitis, at all stages, rest of the vocal organsis LARYNGITIS, [CHRONIC] 117 indispensable; but it is difficult to have it rigor- ously enforced. In the early periods, bloodletting from the arm is sometimes demanded, and in al- most every case, it will be advisable to apply cups to the nape of the neck, or top of the chest; or, what is better, leeches freely over the seat of the disease. Emollient fomentations and poultices, likewise afford relief, but they have been objected to—probably altogether on hypothetical considera- tions—under the idea that they solicit an increased flow of blood towards the throat, and thus aggra- vate the disease. Revellents arc, certainly, impor- tant remedies. A blister may be applied to the top of the sternum, or over the trachea, and as soon as it heals, another should be applied, so as to keep up an intermittent, which is preferable to a permanent, irritation. Hence blisters, thus em- ployed, are better than setons ; and the ointment of the tartrate of antimony and potassa, or the croton oil, is, perhaps, preferable to either. With the view of procuring rest, opium and its preparations may be given. They are useful, likewise, in allaying cough. The salts of morphia may also be employed endermically, and advan- tage has been derived from frictions over the larynx, with the extract of belladonna. Where the affection of the larynx has lost its inflammatory characters, and any of its termina- tions remain, topical remedies may be employed. These have, indeed, been regarded by MM. Trous- seau and Belloq (Practical Treatise on Laryn- geal Phthisis, translated by Dr. Warder, Amer. Med. Lib. Edit. Philad. 1838) as the most effica- cious of all. They may be made to come into immediate contact with the diseased surface itself. At an early period of the disease, inhalations of the steam of warm water may be employed with advantage, but subsequently more excitant appli- cations are needed, to induce a new action in the diseased surface. Inhalations, however, are liable to the inconvenience, that they cannot be restricted to the larynx ; and, consequently, no agents are administered, in this manner, in cases of chronic laryngitis, except such as do not over-excite the mucous membrane of the lungs. The vapour of hot water, to which one of the essential oils has been added, may be used in the way of inhalation, with safety and occasional benefit. Various forms of apparatus have been devised for this purpose; but MM. Trousseau and Belloq frankly confess, that a simple teapot is as well adapted to the pur- pose as the most complicated machines. In this way, chlorine, creasote, and iodine, may be inhaled under the circumstances laid down under Tuber- cular Phthisis. Topical remedies in solution are more to be relied on. Of these, nitrate of silver, corrosive sublimate, sulphate of copper, nitrate of mercury, and Lugol's caustic solution of iodine, (see the writer's New Remedies, 4th edition, Philad. 1843.) have been employed ; but the nitrate of silver is to be preferred, on account of its rapidity of action and harmlessness. It may be used in the propor- tion of ten or fifteen grains to the ounce of water, and it has been prescribed as strong as one part of the nitrate to two parts of water. Various plans have been adopted for applying it. The author uses a mop of rag at the extremity of a piece of whalebone. Others attach a piece of sponge to the end of a quill, dip it in the solution, and having slightly squeezed it to prevent the fluid from dropping, they touch the posterior fauces; raise the outer extremity of the quill so that the sponge may touch the epiglottis and superior part of the larynx, and draw it gently out in this man- ner. Thus, the solution is made to come into immediate contact with the inflamed surface. By others, it has been advised to take up a drop of the strong solution on the bent extremity of a piece of firmly rolled paper, or whalebone, and to cause this to touch the lining membrane of the larynx. It has been suggested, that the solution may be thrown, in the form of a shower, into the larynx, from a small silver syringe, like Anel's; but the plans, already recommended, have the merit of being more easy of application. A plan—before mentioned—proposed by Mr. Cusack, of Dublin, has been regarded by a com- petent witness, Dr. Stokes, (Op. cit.) as the best of all. A brush of lint, of the requisite size, is sewed on the end of the finger of a glove, which is then drawn on the index finger of the right hand. The patient is made to gargle with warm water, and the lint being dipped in the solution, can be readily applied to the larynx. When the disease is dependent upon any syphilitic vice, it may be necessary to administer mercury, or some other revulsive agent—iodine, for example. When mercury is pushed so as to affect the mouth, it sometimes breaks in upon the morbid chain where no vice is suspected or present. It should be given, under such circumstances, so as to exert its ordinary influence slightly on the mouth. When, however, pulmonary tubercles are coexistent, care must be taken in the adminis- tration of this potent remedy, as the dyscrasy, in- duced by it, is apt to cause their development. Where the disease is dependent upon the use of mercury, it should, of course, be carefully abstained from, and an appropriate treatment, in which rest and the free use of iodine are combined, should be prescribed. In many cases, the spasmodic exacerbations are very severe and distressing: they may be assuaged by opiates, or by the application of the emplastrum belladonnas or emplastrum opii. Lastly,—a question may arise as to the neces- sity for the operation of tracheotomy. Although frequently demanded in acute laryngitis, and not to be postponed, it is rarely necessary in cases of chronic laryngitis; but should symptoms, similar to those of acute laryngitis, which demand the operation, arise, it must be unhesitatingly per- formed. It is probable, however, that in such a case, the operation could be of but transient ben- efit; so much disorganization must have occurred as to render ultimate recovery almost wholly, if not wholly hopeless. RoBLEy Dunglison.] LATENT DISEASES__It is a fact familiar to every physician practically conversant with the features of disease, that many disorders, even those of which the presence is commonly indicated by well-marked symptoms, will in particular cases present, throughout the whole or a great part of their course, a material deficiency or total absence of their usual external characters; and that on this account they are frequently on the one hand 118 LATENT DISEASES. confounded with other diseases, on the other en- tirely concealed from observation. Considering the obvious importance of this sub- ject in a practical point of view—especially, it may be added, to those just entering on their pro- fession,—it scarcely seems to have hitherto re- ceived from pathological authors in modern times that systematic attention to which it has an un- doubted claim. In ordinary practice every ob- servant physician is subject to be taken at una- wares by the sudden transformation or sudden de- velopment of the symptoms of diseased action, long latent in the system, and secretly advanced beyond the reach of a remedy. And in the prac- tice of one particular branch of his art, that of medical jurisprudence, nothing is more common than to find his opinion and conduct embarrassed by sudden death arising in the like circumstances —by the discovery of appearances in the dead body adequate apparently to account for death, yet unconnected with any traces of the existence of corresponding disease during life. It would be an object of some consequence then to investigate the subject of latent diseases systematically in both of its relations now mentioned, — to present a classification of the several diseases which are apt to assume a latent course, a sketch of the circum- stances in which they are liable to occur in this form, and an exposition of the phenomena in the living body which may lead to a suspicion or con- viction of their presence, as well as a statement of the evidence by which, in the case of the sud- den extinction of life, we may determine from the appearances in the dead body, taken along with other collateral considerations, what has been the real cause of death. The great extent of the subject, combined with other circumstances, prevents us from undertaking at present what must be to the generality of the profession the more important and interesting de- partment of this inquiry, — that,, namely, which concerns latent diseases in their relations to ordi- nary practice. In undertaking to give some ac- count of their medico-legal relations, it is almost unnecessary to observe, that the writer was first led to review the subject in consequence of its having been often brought forcibly under his at- tention during a period when he was frequently consulted in medico-legal cases, and that the hints which follow are chiefly derived from a consider- ation of what then appeared defective in our knowledge. The importance of latent diseases in respect to medical jurisprudence depends on the considera- tion that sudden death, as one of their results, often leads to a judicial inquiry into its cause! even where no suspicions exist in regard to its manner; that sudden death from latent diseases frequently occurs where collateral circumstances lead to a suspicion of violence ; that they are apt to prove suddenly fatal from the operation of slight violence or of circumstances incidental to violence, such as anger, struggling, or the like ; and that the appearances they leave in the dead body may exist in the same organs, or even also present the same characters, with the appearances occasioned by death from violence of various kinds. On all these accounts latent diseases come frequently be- fore the physician in his medico-legal capacity, and may give rise to medico-legal questions of much nicety. The remarks which follow are in- tended to exemplify what is now stated, and to supply as far as possible the means of investiga- ting the cases here alluded to. These objects will be best attained by considering, first, what diseases are apt to put on a latent character and occasion sudden death ; and next, by what means it may be proved in special cases that they have really been the occasion of death. There are many diseases which may exist for a long time, and even advance so far as to cause decided injury to organs important to life, without seriously incommoding the patient and without occasioning death. Nay, there are many diseases, among those usually marked by prominent symp- toms throughout, which may go on for a length of time and occasion most extensive organic derange- ment, without attracting the attention of the patient or his friends by any external sign, without produ- cing ill health of any kind, and still more without being the occasion of death. In many such in- stances indeed the symptoms proper to the disease are incidentally developed after a time, and then follow their usual course to a favourable or unfa- vourable termination. But often, too, no such development takes place, and death may ensue suddenly, nay instantaneously, either from the disease attaining a certain point incompatible with the further continuance of life, or from some cir- cumstances connected with it of which the opera- tion cannot be satisfactorily traced : and, which is.perhaps still more common, death may be oc- casioned by some other unconnected cause, and the first hint of the existence of latent disease is the discovery in the dead body of extensive alter- ations of structure, such as might be regarded, were it not for such occurrences, wholly inconsis- tent with the discharge of the most important vital functions. It would not be easy to give a complete cata- logue of the diseases which may thus run a latent course. Probably, indeed, such a catalogue would be found to comprise all or nearly all the diseases which give rise to important derangements of structure in the chief internal organs of the body. But it may be of use to indicate those which are most apt to assume the latent form, because such alone appear of material consequence to the prac- titioner. Among the diseases of the head, those which are chiefly apt to present themselves in a latent form are sanguineous apoplexy, inflammation of the cerebral membranes, and inflammation of the substance of the brain. Sanguineous Apoplexy often runs its course so rapidly, although with distinct symptoms, that in reference to practical questions of a medico- legal nature, it presents all the peculiarities and all the importance of a truly latent disease ; but it would be out of place to treat of it in that re- spect at present. In numerous instances, how- ever, sanguineous effusion within the head may take place without occasioning the usual apoplec- tic symptoms, and the individual may live so long that complete recovery takes place by organization and absorption of the clot, or he may be cut off at an earlier period by some other cause. The proof of this is, that clots both old and recent are LATENT DISEASES. 119 not uncommonly found within the head, and more especially in the substance of the brain, where the individual was cut off by a wholly different disease, and where there was sufficient evidence that symptoms of an apoplectic nature never had presented themselves. In a case therefore where the manner of death is doubtful, and a medico- legal examination becomes necessary, it is not enough to account for death that a clot be found in the brain, particularly if it be plainly of some standing. Further evidence may be necessary to connect this appearance with the death of the in- dividual. It is seldom that inflammation of the membranes of the hrain assumes a latent form throughout its whole course, yet in some instances the symptoms are extremely obscure for a time, so that the nature of the disease is at first misunderstood ; and occasionally it has happened that no well-marked indications of disease are de- veloped till a short time before death, and even then the symptoms are merely such as may termi- nate organic affections of the head in general,— namely, stupor, coma, and convulsions. One distinct case in point has been related by the writer elsewhere, that of a middle-aged female, who died suddenly from chronic and circumscribed inflammation of the membranes of the brain. In this case the membranes and also a part of the brain were covered with pus, the corresponding portions of the temporal and occipal bones were denuded and similarly lined with purulent matter, and a portion had even escaped into the cavity of the ear. This affection had commenced in the ' bones at least a twelvemonth before, because the patient had been affected for that time with a purulent discharge from the ear. There can be no doubt, too, that the inflammation of the mem- branes which was the immediate occasion of death, and was produced by the disease of the bone being propagated inwards, must have ex- isted for a considerable length of time, yet no symptom of its existence was detected till she was suddenly seized with acute pain in the head, and then with stupor and convulsions, under which symptoms she died within twenty hours. A case somewhat like this, but where the menin- geal inflammation was more extensive, has been related by Dr. Powell, in the fifth volume of the Transactions of the London College of Physi- cians. But even meningitis of a more diffused cha- racter, and commencing without previous disease in adjacent parts, may likewise put on this singu- lar form, as will appear from the following re- markable case related by Dr. Crispin, in the "Annali Univ. di Medicina." A stout healthy young woman complained for two days of slight headach, without any other indication either of disorder within the head or of any other affection, and was then quite suddenly seized with loss of speech, complete coma, and febrile reaction, under which symptoms she died in the course of the ensuing night. On dissection, there was found suppuration of the arachnoid membrane, while all the other parts of the brain and its membranes, as well as all the other organs of the body, were in the healthy state. (Prospetto Clinico, in Annali, &c. Maggio, 1833.) It is not improbable that to the same head of latent chronic meningitis should be referred those remarkable cases where extensive serous effusion over the brain or within the ventricles has been found after death in persons either dying suddenly without any pre-existing symptoms, or expiring slowly under symptoms wholly unconnected with the morbid appearances. Dr. Abercrombie re- lates an instance of the latter description from the experience of Professor Turner of Edinburgh, where serosity was extensively effused under the membranes of the brain as well as in the ventri- cles, and where the patient presented no signs of an affection of the head, but appeared to be gra- dually worn out by some chronic disorder of the pelvic viscera, which, however, were found to be healthy. (On Diseases of the Brain, p. 214, third edition.) The same author mentions two similar cases from the works of Morgagni and Heberden, in one of which the effused fluid amounted to eight ounces, without any corresponding symptom during life. (Ibid. p. 143.) Perhaps the follow- ing extraordinary instance may be classed with the foregoing. But whether it be viewed as an example of latent meningitis or not, it is well worthy of notice as an illustration of the great difficulty which the occasional occurrence of cases of an allied nature may introduce into medico- legal inquiries, and of the importance of the whole subject of latent diseases. A man of the name of Kennoway was tried in Edinburgh, in 1825, for parricide, under the following circum- stances. His sister left him in a state of furious intoxication, quarrelling and struggling with his father, an old man of seventy, of passionate dis- position, but enjoying good health. On his quit- ting the house she returned—not above seven minutes after she left them together—when she found the old man lying dead on his back, with the marks of two blows on the nose and forehead, not particularly severe. On dissection there was found no fracture of the bone, no extravasation beneath it, no laceration of the brain, but an effu- sion of half a pint of reddish serum in the ven- tricles, and also towards a pint of serum in the cavity of the pleura on each side of the chest. This case presented several other features of in- terest foreign to the object for which it is now referred to. At present it may be observed, that the medical gentlemen who conducted the exami- nation ascribed death to the effusion in the ven- tricles, and the effusion to the blow. But it is quite clear that the latter statement is untenable— that the effusion must have taken a much longer time to collect than seven minutes, and the most rational view of the case seems to be, that the effusion was the result of latent chronic menin- gitis. Among diseases which leave their traces within the head, none is more subject to assume a la- i tent form than inflammation of the cerehral substance. From numerous cases which have been related by various authors, it follows that in I its chronic form inflammation of the cerebral tis- I sue—that,form of disease which is now familiarly known to terminate in suppuration or in softening of the brain—is seldom marked at the beginning by characteristic symptoms; that it often advances I to a great height with scarcely any apparent 120 ■igns of its existence, or even of ill health of any kind, till only a few days before death; and that not unfrcquently it even proves suddenly or al- most instantaneously fatal during a state of appa- rently perfect health. The following illustrations have been already given by the writer in another work, but may be here briefly recapitulated. In a case related by M. Louis, where death slowly terminated an attack of diseased heart, and where no symptoms of an affection of the head occurred at any time, an extensive softening was found in the thalamus and corpus striatum of one side. (Recherches Anat. Pathol. 313.) In another, mentioned by Lancisi, where slight occasional fits of lethargy succeeded an attack of apoplexy, death occurred suddenly more than a year after- wards, and an extensive suppuration of the brain was found surrounding a clot. (De Mort. Subit. p. 12.) In another, which occurred to the writer himself, and which from its circumstances led to a medico-legal investigation, a twelve hours' ill- ness consisting of coma and convulsions preceded death, and there was found superficial circum- scribed ulceration of the anterior lobe of the brain. In another, which likewise occurred in the prac- tice of the writer, a similar superficial softening and ulceration of the surface of the brain over the left orbit was found, although the patient had been affected with coma for an hour and a half only, and had previously enjoyed good health. (Treatise on Poisons, 574.) Lastly, in a remark- able instance described in the London Medical Repository, where death took place instantaneous- ly, without any precursory illness at all, while the individual, a sailor, was pulling an oar, there was discovered on dissection in the central parts of the brain an extensive softening and suppuration, which in the form of an abscess had made its way to the outer surface of the organ. (Vol. ii. 318. N. S.) Diseases of the chest run an obscure or com- pletely latent course much more frequently than diseases of the head, and among these the most remarkable are pleurisy, peripneumony, and or- ganic diseases of the heart. As to pleurisy, it is remarked that sometimes the early, and at other times the middle stage is latent. There are either no symptoms at all, or they are so slight as to escape notice ; or, though obvious at first, they disappear afterwards, and seem to be succeeded by convalescence or even complete re-establishment of health. Lymph and serum, however, or sometimes purulent matter, have in the mean time been effused into the cavity of the chest, and the effusion goes on silently in- creasing till one side of the chest is completely filled, and the corresponding lung compressed and unserviceable. And at length, occasionally after a long interval, the individual is seized with la- borious breathing, and dies in a few days or hours, or even instantaneously. An instance where the interval of obvious ill- ness lasted for a few days, occurred in Edinburgh in January, 1826, and led to a medico-legal in- vestigation, in consequence of the patient's friends having neglected to obtain medical advice, and LATENT DISEASE8. slight at first and severe only for a short time be- fore death, which took place in the course of the third day. On dissection one side of the chest was found filled with serous fluid, together with evident collateral signs of the effusion having been of old standing; and it was ascertained that several months before, recovery had to all appear- ance been attained from a severe attack of pleu- risy and consequent hydrothorax. A more re- markable instance, where the pectoral symptoms subsisted for a few hoars only, is related in Cor- visart's Journal. In this case the patient, who was convalescent from an attack of simple fever, was suddenly taken ill with great oppression in the chest, and died within twenty-four hours, and the left side of the chest was found filled with five pints of serum, and the heart covered with a net-work of lymph, evidently showing the exist- ence of an old pleuro-pericarditis. (Journ. de Med. xxviii. 100.) But the most common cases of the kind under consideration are where the disease is concealed throughout its whole progress, or becomes so after a time, and death takes place instantaneously. Of such a course the following are apt illustrations. A girl in the wards of the Edinburgh Infirmary, under the writer's care, while convalescent apparently from nothing more than a mild attack of simple fever with insignifi- cant pectoral symptoms, suddenly dropped down dead while sitting by the fire and laughing with her fellow-convalescents, and on dissection there was found a copious effusion of serum and lymph into the right side of the chest, with complete condensation of the right lung. An elderly man under the care of another physician of the same hospital was admitted in the agony of suffocation from hydrothorax consequent on pleurisy, but re- covered apparently, and in six weeks was consi- dered nearly fit for being discharged. But one morning, while in the act of making his bed and exerting himself with unusual force, he was seen to drop down on the floor, and the nurse running up to him, found him quite dead. Five pints of serum were found in the right side of the chest, and no other morbid appearance could be discovered. Peripneumony is similarly circumstanced. It is a matter of daily observation, as Laennec has pointed out, that very great differences prevail in different cases in the amount of organic altera- tion which takes place in ordinary cases of inflam- mation of the lungs, before death ensues from oppression of the breathing. It follows that, even in acute inflammation, the function of the lungs may be much interfered with by the inflammatory process, without necessarily endangering life. It is not surprising, then, that where the local inflam- mation is chronic, and the constitutional derange- ment slight or wholly absent, very extensive ravages may be committed by the disease without its giving any local sign of its presence. Many cases might be quoted in illustration of the fact that chronic peripneumony may advance till it completely obstructs a whole lung, without any sign of oppression of the functions of the lungs; and in such cases death may occur suddenly, LATENT DISEASES. 121 A man, who, with the exception of a slight cough, enjoyed excellent health, died suddenly one night, while making a slight effort; and one lung was found wholly disorganized and formed into a sac of purulent matter, which had burst into the general cavity of the pleura. (Diet, des Sc. Med. art. Mart Subite.) Wildberg relates a similar case, which is very striking on account of the cir- cumstances in which it proved fatal. A woman having charged a neighbour with having pilfered herbs in her garden, an altercation ensued, which was brought to a close by the neighbour seizing her by the arms, shaking her violently, and shov- ing her away. She fell down, and in fifteen minutes expired. On opening the body it was found that a large vomica of the left lung had burst into that side of the pleura, and filled it with four pounds of bloody pus. (Prakt. Hand- buch fur Physiker, iii. 255.) It was ascertained that the woman had an attack of peripneumony a year before; but from that time enjoyed good health, except that she complained of trivial cough, and some tightness in the chest. Two similar cases are related in Sedillot's Journal by a French physician, M. Mouton. One was the case of a custom-house officer, who died almost instantly after making a sudden effort in getting on board a vessel; the other was that of a sailor-lad who was found dead in bed, having retired in good health the previous evening. In the former, the right lung was one entire mass of suppuration; in the latter it was almost entirely in a state of carnifica- tion. In referring these cases to peripneumony, it must at the same time be admitted that several of them may be conceived to be instances rather of chronic pleurisy and empyema, having occurred before the late improvements in the pathology of diseases of the chest had led to a more accurate diagnosis of them. Of all the diseases, however, which are the subject of the present sketch, none are of such frequent occurrence as organic diseases of the heart. Diseases of the heart often exist for a long time without a single symptom to attract the attention of the patient or his friends, and often prove instantly fatal without a single precursory warning. Nothing can exceed the irregularity of the circumstances in which such diseases prove fatal. Not only may one man sustain, without inconvenience, an amount of organic injury which cuts short the life of another; not only may one suffer long and cruelly from the same affection in kind as well as degree, which kills another without a moment's previous suffering; but likewise one person may die of a limited extent or degree of a disorder which, in another, reaches an extraordi- nary height without giving a single indication of its presence. It is almost unnecessary to illustrate by examples statements so familiar to all prac- titioners. But as they are nevertheless apt to escape attention in medico-legal investigations, a few instances will be subsequently mentioned, which will at the same time place in a clear light the importance of the present description of dis- eases in the practice of medical jurisprudence. Meanwhile it may be mentioned that, as sudden death from latent organic affections of the heart is the most common of all the varieties of sudden Vol. III. — 16 i death from latent diseases, so is it medico-legally the most interesting and the most important. It would not, at first view, appear probable that pneumothorax ought also to be enumerated among diseases of the chest which may put on a latent course, and prove suddenly fatal. In the most frequent variety of it, which is occasioned by a softened tubercle opening a passage into a bron- chial tube on the one hand, and through the pleura into the cavity of that membrane on the other, the progress of matters is usually marked both by the antecedent symptoms of tubercles in the lungs, and by dyspnoea and other symptoms which succeed the passage of air into the cavity, and precede the fatal termination for a considera- ble interval of time. But at times the antecedent symptoms of tubercles are obscure or wholly absent, and death takes place suddenly at the moment of rupture of the pleura and passage of air into its sac. The following interesting case, which occurred in 1831, in the clinical wards of the Edinburgh In- firmary, under the care of Dr. Graham, establishes the statement now made. An elderly man had been six weeks ill, and during four of these in the hos- pital, on acccount of a dyspeptic complaint, and never presented any symptom to draw attention towards the chest as the seat of disease. At length he suddenly complained of an unesisy feel- ing in the pit of the stomach, and expired at once. The left lung was all studded with tubercles, so as to be almost impervious throughout to the air, and consequently unserviceable in the function of respiration; the right side of the chest was filled with air, so that the right lung, itself not very materially tuberculated, was compressed, and thus rendered unserviceable also; and the air had obviously issued from a recent ulcerated opening in the lower lobe, establishing a communication between the sac of the pleura and a considerable bronchial tube. The cause of the man's sudden death was here quite obvious; and the whole cir- cumstances of the case prove how pneumothorax may be the occasion of instantaneous death, where no reason existed for suspecting the presence of any of the pathological conditions in which it is known to originate. This case leads to the observation, that pul- monary tubercles are very frequently latent for a very great part of their progress. So long as they do not undergo the process of softening, they may gradually invade a large portion of one or even of both lungs, without occasioning any material disturbance to the general health, or even so far disturbing the function of respiration as to attract forcibly the patient's attention. Cases even occur from time to time where tubercles of considerable size have softened and suppurated without the process being indicated by the usual outward symptoms, and without any marked dis- turbance to the general health. These facts are so familiar to every one who is extensively engaged in practice, — especially in hospitals, — that it seems unnecessary to illustrate them by any ex- amples. The writer even knew an instance where numerous tubercles, evidently old, and some of them completely suppurated, were found in the lungs of a friend, who died of a totally different disease; namely, spreading cellular inflammation, L3 LATENT DISEASES. and who, till within a few days of death, was much addicted to athletic exercises. Pulmonary tubercles, which have pursued a silent course, may even prove suddenly fatal; but in such cases there is always some accessory and obvious pathological condition superadded, which is the real cause of the fatal termination. One of these has just been exemplified; namely, pneumo- thorax. Another, of much more frequent occur- rence, is rupture of one of the larger blood-vessels in the lungs, by erosion of its coats, occasioned by the proximity of a tubercle. Diseases of the great vessels within the Chest come under the same designation with diseases of the heart, inasmuch as their course is frequently altogether latent, and their termination in death instantaneous. But in cases of instanta- neous death, the immediate cause of death is always apparent in rupture of the vessel and sud- den hemorrhage. It does not appear that diseases of the great thoracic vessels are ever circumstanced as in those frequent cases of diseases of the heart, where death takes place suddenly without any discoverable accessory pathological phenomenon, to explain why death occurred at the particular period, and not days, weeks, or even months before. Of Diseases of the Abdomen there are several which may run a latent course for a very long time ; but there are few which will remain latent to the last, like many of the diseases men- tioned under the preceding heads. Ulceration of the membranes of the stomach, proceeding from within outwards ; ulceration of the intestines, of the same nature ; ulceration of the gall-bladder, or of the biliary ducts; chronic organic derangement of the great secreting viscera, —more especially of the liver or kidneys ; chronic disease of the coats of the large abdominal vessels; extra-uterine conception, of various kinds ;—may exist for a great length of time, without occasion- ing any characteristic symptoms, or even, at times, any derangement of the health at all. In general, however, as they approach a fatal termination, they develop themselves fully by their external characters. But, on the other hand, they fre- quently prove fatal suddenly, or in a much shorter space of time than usual, in consequence of some incidental pathological change being produced during their progress. Rapid death, from perfora- tion of the stomach or intestines ; from rupture of one of the biliary ducts; sudden death from the rupture of a perforated vessel, or of a brittle spleen; or of an extra-uterine conception, &c, are more or less familiar illustrations of such a course of things. Of the last-mentioned remarka- ble and rather rare accident, the following import- ant example occurred to the writer, a few years ago. The case was a medico-legal one ; a judicial inspection having been ordered in consequence of various circumstances, which it is unnecessary to notice here, having led to a very strong suspicion of poisoning. The female died of a few hours' illness, referable, as it seemed, to irritation in some organ in the abdomen. She had enjoyed good health for some time before, except that four weeks previously she had miscarried about the middle of the second month of pregnancy. On dissection, the abdomen was found to contain I several pounds of recently effused blood; and it, source was a lacerated opening in a Fallopian conception, to all appearance in the course offte third month. The state of advancement of the ovum, the absence of the membrana decidua, and the exact correspondence in the appearances of a corpus luteum in each ovary, showed that the woman had had a twin-conception ; one uterine, the other Fallopian. Another abdominal affection, which it may be right to specify as occasionally assuming the latent form, is the accumulation of worms in the intestines. Intestinal worms com. monly occasion characteristic symptoms; and in some instances they have been known to produce death under symptoms of epilepsy, not merely in children, but likewise in adults. (Treatise on Poisons, p. 590.) But in other circumstances they have been observed to accumulate to an enormous amount, without their presence being suspected till the supervention of a convulsive affection, a short time before death ; and in not i few instances worms have been found abundantly in the intestines, after death from some uncon- nected disease, although they were not indicated by any symptom during the life of the indivi- dual. It is probable that various Diseases of the Spine may put on a latent course; but as the greater part of the organic disorders of this re- gion of the body have been accurately discrimin- ated only in recent times, facts are still wanting on the subject. Meanwhile it is well ascertained that caries of the bones of the spine, though in general it leads sooner or later to the production of symptoms which no observant practitioner cat pass over or mistake, will nevertheless proceed it times to an advanced stage of its progress, and extend widely its devastations without any pro- minent sign of its presence being given forth. It one variety of it, which terminates in dislocation of the processus dentatus of the second vertebra of the neck, instant death may occur, where no suspicion existed of the presence of any disease in the actual seat of mischief. Under this head too may perhaps be arranged a very extraordinary case of sudden death related by Dr. W. Thomtj son of Edinburgh, where the individual, while recovering from an ordinary cold, was found dead in bed, and the only unusual appearance to bt discovered was fracture and dislocation of the processus dentatus, without any disease in the bones or ligaments, and without the slightest possibility of a suspicion of violence. (Edin. Med. and Surg. Journ. xlii. 277.) In cases like this it may not always be easy to feel assured that the ! injury was not inflicted after death in the count of the twisting to which the neck is often sub- jected in opening the head. The preceding remarks on the various disease^ which may run a latent course must be taken If, the reader as mere illustrations of the subject, and by no means as intended to exhaust the list Other diseases are similarly circumstanced. But those which have been specified comprehend bj far the greater number of them ; and they ha«f appeared to the writer, on reference to his o% medico-legal experience, as well as to the vail*- ble and extensive records of medico-legal cases ii German and French journals, to be the most ft* LATENT DISEASES. 123 qoent, and to bear the most important relations to medical jurisprudence. The practical inference to be drawn from what has been already stated is, that, while latent dis- eases by occasioning sudden death frequently give rise to medico-'.egal investigations which are at once cleared up by the inspection of the dead body, we are not always entitled to infer, in cir- cumstances of justifiable suspicion, that the dis- covery of such morbid appearances as indicate the pre-existence of latent disease will account for death,—that the latent disease was the occasion of death. For, during the latent period of the disease, death may have arisen from a different, perhaps a violent cause. This inference is not a mere theoretical deduction, but is amply sup- ported by facts. For example, in Rust's Magazin is related the case of an apothecary who poisoned himself with prussic acid, and in whose body the lower lobe of the left lung was found consolidated and partly cartilaginous. (Mag. fur die gesammte Heilkunde, xiv. 104.) In Corvisart's Journal there is a more remarkable case of a soldier who died of a few hours' illness, and whose right lung was found after death forming, it is said, one entire abscess,—the case being probably one of chronic pleurisy and empyema. Yet this man clearly died of poisoning with hemlock, of which he partook accidentally with several of his com- rades ; and it is not unworthy of notice, as a far- ther illustration of what has been said of pleurisy as a latent disease, that he daily underwent to the very last day of his existence the duties and Fatigues of a military life. (Journal de Med. xxix. 107.) In PyFs memoirs there is a similar account of a woman who enjoyed tolerable health, and lied of a fit of excessive drinking, and in whose jody the whole left lung was found in one mass )f suppuration. (Aufs. und Beobacht. v. 103.) One of the leading peculiarities which renders hese singular cases important in a medico-legal loint of view, in so far as it tends, on the one land, to bring such cases forward in a medico- egal shape, and on the other to render the deci- sion of them sometimes a matter of no small diffi- culty,—is that latent diseases are apt of themselves o prove suddenly fatal under the operation either if slight violence, or of the circumstances acces- mry to violence, such as passion, fright, struggling, ind the like. The following are apposite illustra- ions. A foreigner, who was supposed to labour inder no other disease except the natural infirmi- . ies of a rather advanced period of life, quarrelled >ne evening with his bed-fellow, and in the course >f the quarrel received but one blow, which was nflicted with a stick over the back of the hand. ... lut he immediately fainted, and in three minutes vas dead. The heart presented induration of its . 'alves, but in particular was unusually vascular hroughout its whole substance, and was covered vith a layer of coagulable lymph, clearly showing ■ he pre-existence of one of the most common per- , taps of all latent diseases, pericarditis. (London , rfedical Repository.) A more remarkable and nuch more difficult case occurred to the writer lot many years ago. A pawnbroker who had for long time been often and severely maltreated by pearance found is organic disease of the heart, nr where coma and convulsions immediately precede dissolution, and suppuration and softening of the brain, or the traces of chronic meningitis, are die- covered. In many cases of this kind, however, regard must also be had to the particular speciei of violent death which may happen to be sue- pected ; because it may be that the symptoms an- tecedent to death are common both to the natural and the violent cause. 4. Hence, in many instances, before inferring death to have arisen from a latent disease, of which the traces are found in the dead body, it is farther necessary to determine, by as many proofs as the nature of the case will supply, that violence h improbable, if not out of the question, —and in particular, that the circumstances will not bear out the suspicion of the particular kind of violent death which is imputed. It is seldom that cases occur where this cannot be done, provided a skilful use be made of those mixed medical and general cir- cumstances which no one but a medical man can properly collect or appreciate, but which, at the same time, it is right to observe that even medical men are apt to overlook or mismanage, from in- sufficient acquaintance with the principles of medical jurisprudence. This observation applies with peculiar force to that very common class of medico-legal cases where extraneous circum- stances, in the instances of sudden death from latent disease, have given occasion to a suspicion of poisoning. A skilful toxicologist, who is also a medical jurist, will almost always discover proofs enough to decide the question of poisoning. 5. Additional information, by which much lignl may be often thrown on medico-legal cases involv- ing the question of sudden death from latent dis- ease, is derived from attending to the collateral conditions under which latent diseases are usually observed to prove suddenly fatal. These condi- tions are at feast three in number. Many cases of latent disease have their symptoms first deve- loped, or even prove suddenly fatal, during the additional constitutional disturbance occasioned by a fresh disease. Thus, it is not unusual for death to take place suddenly, in the early stage of convalescence from other diseases. A few years ago, a convalescent in the Royal Infirmary, an athletic young man, who was recovering from a slight attack of fever, followed by a relapse, suddenly called aloud for help, dropped down deadly pale, and died apparently in a faint; and on dissection, there was found considerable en- largement and hypertrophy of the heart, with con- plete adhesion of the pericardium. This U a single characteristic instance of an incident by no means uncommon in hospitals. A second still more common circumstance which concurs with sudden death from latent disease, is some unusual or violent exertion. Several of the cases mentioned above, in illustration of various general facts, will likewise illustrate the present statement Tin LATENT DISEASES —LEPRA. 125 two following, which are related by Lancisi, are also excellent additional examples. A corpulent footman, liable to occasional dropsy of the legs, unequil pulse and uneasy breathing, dropped down dead one day while running after his mas- ter's chariot. The heart was much enlarged, par- ticularly the right ventricle; and the left ven- tricle, usually empty of blood after death, was found much distended, as if it had been unable to expel the blood which was transmitted to it. (De Mort. Subit. i. 46.) Another footman, subject to palpitation and difficult breathing, yet so little in- commoded as to be able to run habitually with his master's chariot, died suddenly after coition; and Lancisi found the heart enlarged to a size exceed- ing that of an ox. A third condition, in which latent diseases have been known to prove suddenly fatal, is during some violent emotion of the mind. This circumstance is even sufficient to occasion death, where the immediate cause of that event is some new accessary derangement of structure in- compatible with the farther maintenance of life. It is a common cause, for example, of rupture of the great thoracic vessels. An interesting medico- legal case of this nature has been related by the late Professor Chaussier. Two men, who had been long on bad terms with each other, met one day in the street, when one of them, who was on horseback, struck the other across the shoulders with a whip. The man who received the blow immediately pursued the rider in a tempest of passion; but he had scarcely advanced a dozen steps when he dropped down, muttered a few in- distinct words, and died. Many people witnessed the affray, and they all believed the deceased had been killed outright by the blow. But on the body being examined, no outward mark of injury could be seen ; and it was subsequently found that an aneurism of the aorta had burst into the cavity of the chest. It is plain from the case for- merly noticed of sudden death from latent pericar- ditis during a quarrel, as might likewise be reason- ably inferred from physiological considerations, that latent diseases may prove suddenly fatal during violent emotions of the mind, even though no new accessary pathological injury be occa- sioned. The general result of the observations on the present head of evidence seems to be, that any circumstance which produces either sudden violent excitement or sudden violent depression of the circulation, may cause instant or speedy death, where extensive organic derangement has accu- mulated silently in any of the important organs of the body. By attending to one or other, or several of the criterions now laid down, it will seldom happen but that an opinion, strongly presumptive, if not even positive, may be formed on the question of the cause of death in the cases which are the subject of the antecedent comments. In some in- stances, however, this is impracticable; and an excellent illustration is the singular case noticed above of instant death after a blow, where there was extensive serous effusion into the ventricles, the effect probably of chronic latent meningitis. The circumstances of death were conformable with the idea of sudden death from violent pas- sion, operating on a frame already brought to a i* peculiar condition by latent disease ; for it was proved that the old man was in a state of high- wrought passion, in consequence of the miscon- duct of his son. But it may also be readily con- ceived that a blow on the head might have the same effect, though quite insufficient to occasion such a result in ordinary circumstances. The prisoner was found guilty of culpable homicide, and transported for life. " R Christwok. * P. O. Hensler. Vom Abendlaii'Jischpn Aussatz im Mittelalter, nebst einein Britrag zur Kenutniss unj Geschichte des Aussatzes. Hamburg, 1702. LEGITIMACY. (See Succession of Inhe- ritance.) LEPRA.— Aiirpa: from Xeirpij-po, scaly/ th. Xtirij, or At'iros, a scale. A scaly disease of the skin, occurring generally in circular patches. At a very early period of medical literature, the con- fusion, which afterwards became " worse con- founded," began to reign concerning the terms lepra and leprosy. The Arabian physicians had described the tubercular elephantiasis, the elephan- tiasis of the lower extremity, and some varieties of scaly disease, under distinct appellations, which became frequently misapplied. When, at the re- vival of learning, the works were rendered into the European languages, the Latin translator multiplied the perplexity by interpreting the Arab ■wwiljuzam by the term lepra, which the Greeks had applied to designate the scaly disease defined above. In the middle ages the term leprosy was indiscriminately applied to the different forms of elephantiasis, the scaly diseases, and, in fact, to any form of chronic skin-disease which was bad enough to entitle the subject of it to admission to the lazar-houses which were established over Europe at that time, where the indigent were glad to get the subsistence they provided at the ex- pense of being called lepers. This confusion has been a subject of complaint with writers from age to age, yet it became perpetuated. Hensler's learned treatise,* written with a view to elucidate the subject, left it nearly as complicated as ever; for he and Sprengel treated under the term leprosy the various forms of elephantiasis, the Greek leuce, and the proper scaly lepra. Many modern writers do not appear to desire the removal of this ob- scurity, as they persist in describing the former of those under the name of leprosy. We trust, how- ever, that medical men will now see the expedi- ency of adhering to Willan's correct nomencla- ture in this instance, which restores to the term lepra its proper and original signification, namely, the scaly disease, the subject of this article. History of the Disease. — Lepra generally begins on the extremities, below the larger joints, where the skin covers but thinly the tibia and ulna respectively. It commences by small, roundish, smooth points, slightly prominent above the sur- face of the skin, which soon become red and shin- ing from being overlaid by minute transparent scales. These become soon detached and replaced by others. The eminences by degrees enlarge ; the scales become thicker, and are chiefly formed on the circumference of each spot. They observe the circular form in spreading, and attain the size of a shilling or a half-crown piece; and as they in- crease, the circular border becomes raised and en- 126 LEPRA. closes a red area, which is free from the squamous : dental secretions, the lymphatic glands sometime, development. A red areola is also perceived ex- | inflame and swells Jjcn^™"""^'"^" <*». ternal to the raised circumference where the scales collect. These orbicular patches, in spreading, touch and intersect one another ; and though in this stage the circular form is lost, we may still trace the segments sufficiently well to show their original conformation. They unite usually first at the elbows and knees, the parts, as we have said, where the disease first shows itself. In the progress of the affection, while the existing patches are enlarging in this manner, new ones arise; the abdomen, the back, and the chest become affected; and in some cases it spreads to the head, face, and hands. The scales fall off and are renewed very fre- quently. Sometimes they are so easily detached and form so rapidly, that the patient's clothes and bed arc filled with scales, which cause some irrita- tion : in other instances they adhere more firmly, and accumulate in such quantity as to impede the motions of the joints,—a still greater source of troublesome annoyance. By their multiplication the scales become aggre- gated apparently in an irregular manner; yet each one is propagated from a centre, and is at- tached by a pulp to the dermoid tissue : this fact is proved by tearing one off, when a slight red speck is seen to project from the middle of the inferior surface, corresponding to a depression in the spot whence it has been displaced. When the disease has lasted long, or is in process of cure, the scales, as they fall, present the reticular emi- nences proper to the cuticle, and leave the surface red, smooth, and marked by corresponding reticu- lations. The description here given will apply to the great majority of cases of lepra, but it presents varieties derived from its extent, duration, and treat- ment. The accidental circumstances of situation and colour also impart to it certain peculiarities. It sometimes covers the whole body, commenc- ing for the most part from the extremities ; it be- gins usually on the two arms and legs at once, and propagates itself, as described, to the trunk; it rarely spreads to any extent on the face : the forehead, the temples, and the external angles of the orbits are, however, often the seat of some scaliness spreading from the hairy scalp. When the scalp becomes affected, the scales are very minute, and generally cover an exudation derived from the inflamed bulbs of the hair; a moisture is also remarked to accompany the scaliness when the disease invades parts where there is a neces- sary friction, or places furnished with many seba- ceous follicles,—as the nates and inside of the thighs, the axilla, the verge of the arms, &c. These form exceptions, however ; for it is one of the essential characters of the disease that the de- squamation is quite dry. In cases of a very chronic nature, where the not admit into the description of lepra the rh*. gades and ulcerations which are mentioned in his excellent work. (Specielfe Therapie, voL vi, p. 440.) A remarkable appearance which lepra some- times assumes has induced accurate observers to recognise in it a peculiar species of the disease, It has been observed on parts of the trunk that a complete desquamation over a considerable sur- face takes place without being followed by any re- production of scales in this particular place: it re- mains red and smooth, and still affects the circular form ; and not only is the whole area round and bordered by a slightly raised margin, but it con- tains within it some patches, either circular or ob- viously showing a disposition to that form, yet without scales either on the centres or the raised borders — their usual nidus. What makes this variety more remarkable is, that whilst the patches exhibit this feature probably on the back, it is as scaly as ever on the extremities. We must not, however, suppose that this partial absence of scali- ness in such rare cases makes any exception worth notice in the history of lepra ; in some instances it probably depends on idiosyncrasy, but we think it is more frequently a partial curative effort of nature, or the effect of medicine, which from some unaccountable cause is arrested after having pro- ceeded only so far as to check the morbid secre- tion of the cuticle, the vascularity still remaining. This explanation is rendered the more plausible if we consider the locality of the phenomenon, and the manner in which the disease usually advaneee towards a cure in the cases where we can trace its disappearance under the influence of medicine. Its situation, as we have said, is on the trunk, almost invariably on the back ; and it is here that, when lepra begins to yield to any of the methods of treatment to be mentioned afterwards, the effect is first visible.* The constitutional disturbance attending on lepra is for the most part very trifling, particularly when we consider the large cutaneous surface which is frequently engaged ; sometimes a slight fever, accompanied with gastric symptoms, coin- cides with its first attack; but when established, it goes on for months and years without constitu- tional symptoms of any import arising from it Its most troublesome accompaniment is a disa- greeable pruritus, which attends its commence- ment and increase. This occurs particularly when the circulation is excited by exercise or full diet, and when the warmth of bed exalts the cutaneous action: it is sometimes aggravated to a burning heat which is most intolerable. This itching and tingling is not peculiar to lepra, but is met with in most diseases of the skin attended with infiam- inn^c PPH-arS to be a law '" Pa'hology that the n-solu- disease is of such extent as to spread over the ^{^^Tl^^,^ ^^^ hands and invade the root of the nails, these be- come much altered in structure, curved, and of a dirty yellow colour. It has been observed in some rare instances that the dermoid tissue which secretes the nail has become inflamed and fur- nished a sanious discharge. (Ruyer.) In the cases which are complicated by any of fhose acci- Hull->•- »,-. „* .1.......r,tu»'''mu 13 All tllBUI'l rl'rpnt r? C hoscoP,sts, yielding first where it is whfrh wl ,h 0,s"metimes air,)rtls an "ample of a «... 5 £? we th'»k's analogous to the appearance of lepra £?.'.ch "5 ar.e d.scussinu.-we mean those cases which most a state cases i eniory of ac- aira'tP nh ' pres."1 """"selves to the memory oi at- a certa°n „ ,??• " he,re ,Ue P'«»««>»ia. after proceedin, neUnlr^nh yi,0Vard8Jre"olut,on> "-"wins stationary, te«Ckw^ n°r f"rw»m«- 'I'Uis appears u icuiarlv h» mm IS'* the 'Weanmce adverted to par- ticularly by MM. Cazenave and Schedel. LEPRA. 127 mation, and is often present in a greater or less degree as a symptom of internal disease. Mr. Plumbe's explanation of this phenomenon is too mechanical, and, though ingenious, inadmissible. He thinks that it is to be referred to the raising up of the scales by the increasing development of the " inflamed margin, and fresh growth of scales, the centre which was attached to the cutis being thus forcibly torn from such attachment." He sup- ports this opinion by the observation that the pricking occurs most constantly at the commence- ment, when the new scales are oftenest detached, and seldom happens when the disease is subsiding. We consider this pruritus to be a morbid sensa- tion, depending probably on an altered secretion in the skin, and the reason appears to be very ob- vious why it happens in the commencement. The morbid secretion which forms the scale affects the sensibility of the skin more strongly at first, when the impression is new, than afterwards, when the squamous deposits become an accustomed stimulus to it; and besides at this period the cutaneous sen- sibility becomes somewhat impaired : the subsi- dence of the disease is of course not marked by pruritus, as the vascular irregularity producing the scaly secretion is now returning to the physiolo- gical state. This explanation is applicable to the itching and tingling of other cutaneous affections, and to that which is symptomatic of hepatic and other visceral derangement.* Hippocrates re- marked that the pruritus increased before rain. Although much constitutional disturbance be rare, yet if lepra spread over the whole body, and is severe in degree, it often produces some anxiety and febrile excitement, partly from the general ex- tension of the sub-inflammatory state of the skin, and partly from the mere mechanical annoyance that the scaly incasement gives rise to by obstructing the free motion of the joints, which become some- times painfully tense, and so stiff as to oblige the patient to keep his bed. Willan and Bateman, endeavouring to systema- tise different terms used by the Greek writers, divide their genus lepra into three species, a divi- sion which is considered unnecessary by the most judicious writers. Their lepra vulgaris is the dis- ease we have described here, and comprehends all the varieties. Lepra alphoides is a mere variety of the com- mon lepra, possessing the same essential charac- ters, and requiring similar treatment. It is a form in which there is less redness of the skin and ele- vation of the circular margins : the scales also are smaller, and of a more pearly whiteness. It sel- dom reaches the trunk, and it generally attacks children, aged persons, or those of a weakly habit of body. It appears to be a variety of the dis- ease in which the morbid action is less energetic, modified probably by some constitutional pecu- liarity. Lepra nigricans is confessedly a rare form. M. Bictt insists that this has invariably a sy- * There is an analogy between those morbid sensa- tions of itching, pricking, tingling, &c, arid the in usee volitantcs, flashes of light, and tinnitus aurium. They are all irregular impressions on the sentient extremities of the nerves; in the latter on those of vision and hear- ing, in the former on the nerves of touch, Diseases of the chylopoietic vUcera and the brain give rise to both classes of vitiated sensations. philitic origin, and we agree with him in this view of it. Secondary syphilis, as it assumes almost every form of cutaneous disease, appears sometimes under that of lepra. It is a question with patho- logists whether the syphilitic diseases of the skin are to be separated from the others in nosological arrangement: they agree in anatomical characters, put on the same form, and in many instances yield, temporarily at least, to the same treatment. Notwithstanding these points of agreement, how- ever, the most esteemed authors consider that they should form a separate class. Their venereal origin furnishes a much more important reason for distinguishing them than any consideration arising from their agreement in form affords for keeping them together, as it is an indication for a special line of treatment, the disregard of which might be attended with disastrous consequences. Lepra more commonly affects men than women, but the difference as to sex is inconsiderable. Youth and middle life are more liable to it than infancy or old age; but no age is exempt from it, after the first dentition to the latest period of life. It appears to be less affected than the other skin- diseases by the influence of seasons ; but it is ob- served to be most common in autumn. Differ- ences of condition and circumstances in life have not a decided influence on it, except so far as they favour the development of the predisposing cause. Willan considered cold and moisture to be a fre- quent cause of it, and says that it is often excited by external irritants and dry sordes on the skin. Bateman differs with him in this, as he has seen it frequently in persons whose respectable rank and circumstances precluded these causes, while he has not observed that certain classes of work- men, necessarily exposed to them, were particu- larly affected with it. Like the other cutaneous diseases, it has been known to succeed to a disor- dered state of the digestive tube and of the biliary organs; but we must consider in these cases that there has been a great predisposition present; and it is one of the diseases where the latter acts a principal part. Where a predisposition prevails, the slightest causes are sufficient to give rise to it; thus it has been produced by highly seasoned food, spirituous potations, violent exercise, and strong emotions of the mind ; anger is said to be a frequent exciting cause of it: mental depression also produces it, especially that arising from un- expected poverty and the bad diet accompanying it, as in the interesting case narrated by Dr. Mackintosh. (Practice of Physic, vol. ii. p. a 17.) It is quite certain that lepra is not contagious; and discussions on the subject could only have been entertained when a total disregard of preci- sion permitted diseases of the most distinct na- ture to be classed under this most abused term. Pathology.—It is sufficiently obvious from the enumeration of occasional causes, that we are not aware of any determinate conditions in its origin. That lepra is an inflammatory disease there can be no doubt; but as the term inflamma- tion does not convey any very defined notion as to proximate causes, this is but a vague account to give of its etiology. We cannot in fact con- ceive any change taking place in the organization of the skin without a change in the organic action 128 LEPRA, of its ultimate tissue or capillary vessels; and wherever this takes place, it constitutes a pheno- menon which has hitherto been denominated in- flammation. Observation of the mottled arms of healthy infants shows that the cutaneous capilla- ries in their physiological state affect something like an orbicular arrangement; and this might be in some measure connected with the fact, that most inflammations of the skin originally observe a rounded form. Further than such a simple step, however, our knowledge does not permit us to advance in the etiology of this, or indeed of any other skin-diseases. In Mr. Plumbe's work an attempt is made to ground the pathology of cuta- neous diseases on the part of the dermoid tissue affected, and to specify the class of vessels diseased in each morbid alteration. This would be very desirable, but is wholly unattainable in our pre- sent state of knowledge. Anatomy teaches us hardly any thing about the arrangement of the capillaries of the skin. We are totally ignorant as to whether there be separate vessels for the se- cretion of the tissue of the corium, the rete mu- cosum, and cuticle; and whether the transpiration and sebaceous matter are furnished by these, or have separate vessels for their elaboration: it is gratuitous, therefore, to say that the seat of the inflammatory action which constitutes lepra is in the vessels which secrete the cuticle, merely be- cause cuticle is the product of the inflammation; for this is to assume that the different tissues are formed by diflerent vessels, a conclusion which has never been proved, and which modern physi- ology gives reason to suspect is untrue. If the argument were admitted, it would infer a separate set of vessels for every product of inflammation of the skin. It is, however, unsuitable to proceed with a discussion of this nature in this place. Diagnosis*—The disease which most resem- bles lepra is psoriasis. The earliest observers of squamous diseases marked the difference which exists between them. Paul of Egina marks the distinction which depends on their form, in these words: " Xfapa per profunditatem corporum, cutem depascitur orbiculatiori modo, et squamis piscium squamis similes dimittit. *upa (psoriasis of the moderns) autem magis in superficie fweret, varie figurata est;" but if no other difference existed than their configuration, we might be induced to follow the example of some respectable authori- ties, and to describe them together as mere varie- ties of the same disease. They differ, however, in more essential respects. Lepra is a more chronic disease than psoriasis, both as to duration and effects; it does not excite the same amount of sympathetic disturbance in the constitution, and is less affected by the relations of tempera- ment, seasons, climate, &c.; in fact when it once sets in, it appears to become more inveterately wedded to the constitution than its congener, which, although it produces greater local and ge- neral irritation, is yet more amenable to the re- sources of medicine. Its general aspect, indeed, sufficiently distinguishes it from every species of psoriasis except one. The circular margins en- closing the central red part free from scales are quite contrasted with the irregular scaliness of psoriasis, cracked often by rhagades and ulcera- tions. The psoriasis guttata, however, appears to be a near approach to the character of lepra, and to constitute a natural alliance between them: the same round spots, gradually increasing and be. coming covered with scales, characterize both, U| it is only at the very first stage and at its decJan. sion that they are very similar; for when it u fully formed, the patches are much larger, and have assumed the annular form mentioned above, whereas the smallness of the patches, their whole surface being covered with minute furfuraceone scales in psoriasis, is sufficiently characteristic, so that whilst their agreement in some things showa them to belong to the same family, yet there ap. pear to be sufficient points of peculiarity in each to enable a careful observer to make a tolerably confident diagnosis. Several eminent writers are strenuous advocates for their being united on the grounds of similarity, and lean much on the fact that sometimes in psoriasis there are present some patches which have all the characters of lepra. We acknowledge this fact, but we do not think it a valid argument, as it would hold good for uni- ting many cutaneous diseases which all agree to separate, as, for instance, eczema and impetigo, because the vesicles of the former are frequently intermixed with the pustules of the latter. While, therefore, we acknowledge their affinity, and that their treatment is similar, yet, from the differences detailed above, and these as particularly affecting their prognosis, we are for maintaining them dis- tinct, and the weight of authority is on our side. There is a possibility of confounding some other diseases, which affect a circular form, with lepra. In the state of the ring-worm of the scalp, when the purulent incrustations are detached, a red ring remains, which is sometimes covered with a slight scaliness. This might be mistaken for a lepra of the scalp, and the more so if the porrigo be a little developed on the body ; but a little atten- tion will detect the difference between the aspect of the ring-worm and the leprous patches; the for- mer is covered over with a small laminar scab rather than a semi-transparent scale: the hair, which falls in the ring-worm, is preserved in lepra, and a few days' watching will develop the favous pustules from which the scab is secreted. If con- tagion can be established, as it generally can in the porrigo scutulata, it decides the question at once; but the chief element in the diagnosis is derived from considering that it is much rarer fcr the porrigo to be found on the trunk and extremi- ties, than for lepra to be seen on the head, and that respectively they for the most part spread in contrary ways, the lepra from the extremities and trunk to the head, the porrigo from the head to the body. (MM. Cazenave et Schedel, Maladies de la Peau d'apres M. Biett.) With respect to the syphilitic eruptions which assume the guise of lepra, their diagnosis is not difficult, and this fortunately, as it is of more im- portance to be positive in this case than the for- mer, the consequences of mistake being much more serious. The syphilitic squamous disease, called by Willan and others lepra nigricans, re- presents the figure of lepra ; but the violet, cop pery, or black colour, which is its essential cha- racteristic, is quite sufficient to stamp its origin. The round, flattened, circumscribed concretions constituting the tubercular syphilis, called some- LEPRA. 129 times by us incorrectly pustular eruption, might impose on us also for lepra; but here the coppery colour, which is happily for our diagnosis an in- separable companion to the venereal taint, comes again to our aid. But even if we had not this unerring distinction, a little' examination evinces that the tubercular spots, although disposed in rings, are very different from the circular patches; and the thin squamous lamina, which is some- times observed on the tubercles, is disposed just the reverse of the leprous scales : it spreads from the centre, and is only a partial covering, never large enough to conceal the circumscribed indura- tion which projects beneath. Prognosis.—Lepra is to be reckoned, under the most favourable circumstances, as a disease very difficult of cure, and in many cases incurable. In old or debilitated subjects, scarcely any means are sufficient to eradicate it; but in those of an oppo- site habit success is never to be despaired of, as there are many cases on record of its being quite removed after twelve and sixteen years' standing. It is not dangerous when it is a primary disease ; for even when nearly the whole skin is encased by its scaly concretions, the injury of its function seldom involves the system in general disorder. This is a statement of a general rule, to which, of coarse, exceptions will be found in those whose organization is bound together by a greater sym- pathy—idiosyncrasies* of constitution, which it is impossible to foresee as it is to explain when de- veloped. The obstinacy with which it adheres when once engrafted on the system, shows itself sometimes by the inefficacy of every means to pre- vent it spreading over the whole body ; and again, in other cases it disappears spontaneously or under the influence of medicine, in one place, and while the patient is congratulating himself on its depar- ture, it suddenly appears in another part of the body. On the other hand, it has been known, after lasting for months, or even for years, gradu- ally to subside of its own accord under the influ- ence of some of those inexplicable changes to which the human body is liable. It appears to have sometimes gone on to a fatal termination ; and the description of its ultimate encroachment on the vital functions, while it suggests phthisis, presents some singular features. " The local dis- ease having reached its highest degree, a remark- able constitutional affection appears. The patient now becomes very languid ; asthmatic, particularly at night-time; smothering fits seize him; he coughs violently and spasmodically, and spends the night in perfect sleeplessness, falling into ex- cessive, colliquative, clammy sweats, which give an intolerably fetid odour. His voice becomes weaker and hoarser; the appetite for food and drink is prcternaturally increased; and the temper becomes gloomy. Finally, various nervous symp- toms arise, faintings, convulsions, paralysis of some parts, and death arrives preceded by the highest degree of exhaustion." (Richter, Specielle The- rapie, vol. vi. p. 440.) Treatment. — The history of the treatment * We owe an apology for the use of this word, which is, indeed, but a confession of ignorance, although cloaked by so learned a term. It really means that the fnct which is referred to it cannot be explained by any recognised law in pathology. Vol. III.—17 which has been from time to time employed pre- sents a picture of the prevailing medical dogmas, and at the same time indicates the obstinate na- ture of the disease ; for where so many various remedies have been lauded for their success, it only proves that experience has not established that any one has been generally successful. It would take up a large space to furnish a mere catalogue of the various substances which the three kingdoms of nature have been ransacked to supply for the cure of this disease in different ages. Empiricism, aided by superstition, was, in the early times, perpetually devising something new from the animal kingdom; from the flesh of the harmless ass, recommended by Hippocrates and mentioned with applause in the writings of T. Bartoline, and the bull-frogs of Myzaldus, to the poisonous viper, which Galen hails as one of those great discoveries which accident has fur- nished to mankind. (De Simpl. Med. Facult. lib. xi.) In the vegetable and mineral kingdoms, al- most every article used as a drug has had, at one time or other, its favourers, from the most inno- cent herb to arsenic; and each has been extolled as a specific. In describing the treatment, how- ever, we shall only take notice of those remedies of which the efficacy has been proved by the ex- perience of men who have made their therapeutic virtues the subject of investigation since cutane- ous diseases have been studied after the modern improvements in pathology. One great reason why remedies have been ex- tolled beyond measure by some as certain speci- fics, and denounced unmeritedly by others as quite useless, is, that former writers have mostly ne- glected to mark the particular features of each case in which their remedy succeeded or failed. Having determined that it was the leprosy they had to do with, they appear to have gone to work with their favourite nostrum, without taking into account, or at least without recording, the most important therapeutical indications of the affection. The first grand consideration in a rational treat- ment has respect to the cause. Can we trace its dependence on any internal disease 1 If so, it is vain to expect its cure until the primary disorder be successfully attacked ; while it is unpathologi- cal to make it the object of chief attention : we say chief, because, although only a symptom, yet it is not, even in this case, to be entirely neglected, as its reaction may have a powerful influence on the original focus of the disease, and this in two ways, which it is highly important to distinguish. Its appearance on the skin may afford a salutary natural derivation, and in this case it would of course be injurious to endeavour by treatment to repel it: in another instance the disease of the skin may be only an additional source of morbid action, and react on the primary affection in a prejudicial manner; so that here, although but a secondary phenomenon, it must become an object of treat- ment. It is only tact and much observation that can discern these diflerent circumstances; they do not often, however, fall under consideration, as lepra is one of the cutaneous inflammations least frequently complicated with organic disease of the viscera. It needs scarcely be mentioned that if the skin affection can be traced to any external cause, whe- 130 LEPRA. tbar it be mechanical irritants peculiar to any trade or locality, or endemic agents operating through the atmosphere, the patient must be with- drawn from their influence. Thus, if it occurs from the influence of a cold and moist climate, or that it can be imputed to sordes on the skin, (both which circumstances Willan reckoned as common causes,) in the first instance the patient should re- move to a dry atmosphere; and in the latter he should change his occupation to some that would not necessarily expose him to the exciting cause ; and it is the medical man's duty, if he have ascer- tained any of these sources, to insist upon the ab- solute necessity of taking this step, being aware that the comfort which flows from health may be taken from the patient for the remainder of his life if he neglect it. The cause being investigated, and the treatment with respect to it having been considered, the age and constitution of the patient, and the extent and duration of the cutaneous affection, are the cir- cumstances upon which we ground our judgment in proceeding to apply remedies for its cure. If the patient be young and strong, (and lepra usu- ally occurs in such patients,) general bleeding must be performed; and if the disease has not be- come very widely extended, and inveterately chro- nic, the abstraction of blood by the lancet will fre- quently be attended with great benefit. The ap- plication of leeches in the neighbourhood of the leprous patches is also very effectual ; and the dis- ease in some instances yields to a few general bleedings, accompanied by leeching. The local bleeding by leeches is inadmissible when the ma- lady has extended over the whole or a great part of the body ; but when it is confined to one or both arms or legs, we can speak in the most de- cided manner of the great benefit derived from their use. In the comparatively recent cases the application of leeches two or three times, preceded by abstraction of blood from the arm, will be ge- nerally followed by a great diminution of the central and external redness and of the desquama- tion ; in fact, sometimes by a speedy disappear- ance of the disease without the use of any other measures of importance. The circumstances which peculiarly demand the abstraction of blood are, an active irritable state of the patches, and the existence of feverish- ness or great uneasiness from the prickling sensa- tions ; but it has of late years been proved that bloodletting is an excellent adjuvant to other means. In fact, a great improvement in the treat- ment of skin-diseases generally has taken place since the utility of bloodletting has been recog- nised in reducing the inflammation from an active to a passive state. It will much facilitate the cure of even the smallest extent of the disease to be- gin by a good bleeding; but it is in cases where it has spread very generally over the body that the bleeding is to be mainly depended on, at least at the outset of the treatment. Dr. Duffin, whose large experience of this remedy is very favourable to its use, after pointing out its striking usefulness in the circumstances adverted to above as peculiarly requiring it, adds, " but supposing that there exist no general symp- toms, still this mode of treatment is very often proper, were it had recourse to with no other view than to subdue the irritability of the skin or its extreme susceptibility to disease. But it has another good effect—it induces a state of the sys- tem that admits of being much sooner affected by the use of arsenic, when the active symptoms have been so far subdued as to allow of the em- ployment of that medicine." Its effect as a pre- parative is, indeed, the chief improvement we al- luded to; and since it has been so employed, many remedies whose efficacy was much debated are now found decidedly useful, their exhibition being preceded by a bloodletting, and recourse being had to it during their use occasionally, if any symptom of the active inflammation re-appear, It would be obviously improper to employ it if the patient be in a debilitated state, the effects of a bad constitution, of the long duration of the disease, or of old age. Amongst the external remedies the bath is in- disputably the most effective, and most generally used. The simple tepid water is very much em- ployed, and is not superseded by the many new methods of bathing or vapourizing the surface. The painful stiffness and irritation are almost al- ways relieved by a twenty minutes' immersion in water at 90° : it appears to us to promote clean- liness, and a softening and falling off of the scales, just as well as the vapour-bath; but the latter is preferred by many experienced practitioners. The tepid salt-water bath is still more effectual as a stimulant to the skin; but it is to be used only when the inflammatory state has been entirely re- moved by the antiphlogistic measures. Much expectation had been raised as to the efficiency of medicated vapours in this and the other squamous diseases; but their superiority to the ordinary baths has not been demonstrated. The sulphur vapour-bath is the most powerful stimulant amongst them, and it has certainly been used successfully in some obstinate cases ; it must, therefore, be kept on the practitioner's list, to be employed where other remedies are inapplicable or have already failed. The vapours of tar and of acetic acid have been much used, but they are not so highly esteemed as those of sulphur; but, indeed, experience has not established for any of those fumigations the virtues which were pro- claimed at their first trials. Bathing in the medi- cinal waters containing sulphur, such as Harrow- gate, Lucan, Leak, St. Gervaise, &c. is decidedly a means of great power in scaly diseases, and many extraordinary cures are attributed to their use. When they are recommended, and the pa- tient cannot remove to any sulphureous spring, a useful substitute may be readily made by dissolving six ounces of the sulphuret of potash in ten gal- lons of tepid water, and adding a small quantity of the sulphate and muriate of soda (eight ounces of each.) Bathing, however, whether it be local or general, and medicinal fumigations, are only to be relied on as a secondary remedy; they are not to be used till the active irritation be removed by depletory measures; and it follows from this that they are particularly applicable in the chronic cases, and in patients of a debilitated habit, where the disease is but little energetic: they must be persisted in for some time to produce a beneficial effect, and the vulgar opinion that they weaken the constitution is to be entirely disregarded, for LEPRA. 131 the contrary is the fact, as the patients will be found to derive strength from every means that exerts a salutary influence on the cutaneous dis- ease. In many states of the skin where tepid bathing is advisable, its action will be much aided hy gentle friction with a soft flesh-brush, the use of which is deservedly extolled by some writers. Topical applications in the form of ointments and lotions are very useful in many cases. They are intended either to allay irritability, or, from their stimulating effects, directly to attack the dis- ease by altering the action of the skin. In the former kind is reckoned the Carron liniment, which, spread over the leprous patches has been found to cool the skin, and keep it soft and com- fortable ; the addition of two drachms of oil of turpentine to eight ounces of it, renders it a gen- tle stimulus which can be borne in almost all cases, and adds much to its good effects; it is one of the simplest applications, and can be used over a greater surface than others of a more powerful nature. Dr. Duffin prefers an ointment composed of equal parts of diluted citrine oint- ment and tar ointment to any other topical remedy in the chronic cases, and states that it may be applied very extensively over the body without dreading its affecting the mouth, or producing any other of the effects peculiar to mercury. The patient is to be directed to remove the old oint- ment perfectly previously to laying on a fresh ap- plication, and to use for this purpose an alkaline lotion, made of two drachms of liquor potassre to six ounces of water. The ointment adheres with great tenacity, and he " thus unconsciously sub- mits the parts to a very perfect ablution and con- siderable friction, two agents of the utility of which no person can doubt in the case of lepra." M. Biett, who thinks that ointments in general are of but little service, yet places confidence in one composed of the ioduret of sulphur and lard, twelve or fifteen grains of the former to the ounce of the latter. It is a very valuable remedy in recent lepra, occurring in a weakly individual who could not tolerate active internal medicines: it should be applied by a gentle friction to a few patches at a time, after a tepid bath: the skin's activity increases under its use ; the circular eleva- tions are reduced to its level, and the scales fall; and when the natural state is nearly restored in one part, new patches are to be attacked, until the resolution becomes complete. Besides the Carron liniment mentioned before, the smearing of the patches with cream or with fresh butter, [or with cod-liver oil,] has been ex- tolled as very efficacious in allaying irritation from the rigidity of the skin ; and we can recommend with confidence the use of these emollients as ex- cellent adjuncts to the general means of bleeding and purgatives, (which must be the chief reliance as we have mentioned before,) when the heat, itching, and stiffness give great annoyance. A lotion that was held in much repute for de- taching the scales when they adhere tenaciously, is a decoction of the stalks of dulcamara with some alkali : it is said even to bring the skin to a healthier condition. We should remark that benefit from these external applications, liniments, oint- ments, &c., is to be looked for chiefly when the disease is confined to the extremities, and shows little disposition to spread. [In chronic cases, the ointment of iodide of mercury; or a liniment of the red iodide, or an ointment of the same; or the solution of iodide of mercury and arsenic, diluted with an equal quan- tity of water; or the tar ointment; or an ointment of creasote, or a liniment of the same; or an ointment of the sesqui-iodide of carbon, or of the iodide of ammonium, has been prescribed in the same cases as the iodide of sulphur. It has, also, been advised, that the patches should be touched with a liniment, composed of olive oil and rose- water, each an ounce, liquor potassse, half an ounce; and, when they are small, they may be sometimes touched with advantage with strong acetic acid, or aromatic vinegar, or the mineral acids, when diluted : but, as elsewhere remarked, (Practice of Medicine, 2d edit. p. 137,) care, it need scarcely be said, must be had in the employment of these potent agents, and they never can be proper in the early and inflammatory stage. Recently, anthra- kokali and fuligokali—simple and sulphuretted— have been recommended, both internally and ex- ternally; and Mr. E. Wilson (On Diseases of the Skin, Amer. edit. p. 360, Philad. 1843,) affirms, that he has employed fuligokali in several cases of lepra and psoriasis, and especially in psoriasis pul- maris, and with better success than he had obtained by the usual remedies. The preparation and mode of administering these remedies are given else- where. (New Remedies, 4th edit. p. 57, and p. 321.) Cantharides have likewise been prescribed ex- ternally. Dr. Davidson of Glasgow, (Lond. and Edinb. Monthly Jour, of Med. Science,T)ec. 1841,) noted the comparative effect of iodide of sulphur, and the Acetum Cantharidis of the Edinburgh Pharmacopoeia, in an inveterate case of several years' standing, in which a variety of remedies had been tried in vain. The iodide of sulphur was applied to the lower extremities, and the acetum cantharidis to the arms ; and, from the result of his observations, he is satisfied that the latter had more power as a local agent. He found, however, the proportion of cantharides in the official formula too small, and therefore doubled it. Dr. Davidson recommends the following liniment, which is a modification of the Emplastrum Cantharidis of the Edinburgh Pharmacopoeia, as superior to any preparation he has tried. It is sufficiently soft during warm weather to be applied with a brush; but requires to be heated when the temperature is low. (Adipis, 01 Rapii, Caniharid, pulv. ai £i.) In order to succeed with any of these vesicating agents, the skin should be previously softened, either by the warm bath, or by sponging with warm water.] The most effectual means for combating lepra are, however, to be sought for in the internal me- dicines ; and the experience of able observers has proved a great number of these to possess undeni- able power. The use of different medicated waters, as those of Harrowgate and Leamington in England, and of the different waters on the continent which contain sulphur, has been a long time established as very beneficial; we have of late had occasion to know of several cases that have been cured by LEPRA. drinking the water of Lucan Spa which resembles the Harrowgate, but is not so strongly impregnated with sulphuretted hydrogen. This is a much better way of administering the sulphur internally than either the simple flores sulphuris, or in com- bination with antimony, the golden sulphuret of which was once a favourite remedy in cutaneous diseases. The mineral waters should, if possible, be drunk at the source, or at least be procured from it: as it is a fact that their imitations are not so efficacious as the waters of the springs. The dulcamara has certainly properties which entitle it to notice. Dr. Crichton's testimony was very strong in its favour, and brought it much into rise in the treatment of lepra. He states that out of twenty-three cases in which he employed it, only two resisted its action; two or three ounces of the decoction of the twigs and leaves were used by him thrice a-day; but we cannot help being inclined to attribute his success rather to the other means which he used, as the experience of other physicians who have used it still more ex- tensively does not corroborate its virtues: it is still used, however, as an adjunct, in chronic cases. Decoctions of the acrid stimulant plants, daphne mezereon, d. enidium, and of guaiacum, have been used with success in different instances. The compound decoction of sarsaparilla has also en- joyed much reputation, and may be recommended for its stimulant effects on the skin : its use should alternate with some of the more powerful remedies to be mentioned. A remedy which at one time was extolled to an extravagant degree, and has fallen in late times into as undeserved disrepute, is the tar-water; but we are persuaded on the grounds of experience that it docs possess real efficacy A case has been communicated to us, which had been treated by some of the roost eminent practitioners with the most powerful remedies: but no effect was pro- duced on the disease till.tar-water was tried by a physician whose experience of it led him to place much confidence in it; and under its use the pa- tient got quite well. Half-a-pint of it should be drunk three times a-day. In the case alluded to the patient was made to walk rapidly until he began to perspire, and then to s'K for a time in a warm room, and much importance was attached to this manner of exhibiting it. Pitch pills are also to be mentioned as a remedy to which expe- rience bears a very satisfactory testimony; six or eight of them, each five grains, should be taken for a dose three times a day, and this will have to be increased by degrees according to circumstances. Some English writers praise very highly the treatment by mercurial preparations; and in some cases minute doses of corrosive sublimate have proved of unquestionable utility, salivation by mercury being, however, seldom undertaken in the cure of lepra. The naive relation which that re- spectable writer, Dr. Turner,* gives of its effects in two cases where he employed it, would answer for its history in most cases ; and as a purgative indeed, calomel will be very beneficial in occasional doses, no matter what plan of treatment be pre- + A Treatise of Diseases incident to the Skin, by Daniel Turner, of the College of Physicians, London 3d edit. 17-J6, p. 30, et seq. ferred; and in children particularly it is a very useful means. We now come to speak of arsenic, a remedy that has been of late years much investigated as to its effects in squamous diseases. \\ bile some have found it to possess uncommon virtues, others have decried it as not only useless but dangerous. It is, without doubt, a very dangerous remedy in the hands of incautious practitioners, and will never prove useful if it be employed where cir- cumstances contra-indicate it. But we must ex- press our suspicion that where it has failed, it hag been for want of discriminating between the states which are favourable to its action, and where its administration is improper. It is superfluous to say that its exhibition requires the most cautious attention on the part of the practitioner; and we are confident, that where it is judiciously em- ployed, it is not only a safe but a very valuable remedy. It seems to be peculiarly applicable in those cases which are seldom benefited by other medicines — we mean those instances in which the lepra has lasted for several years, and has in- vaded nearly the whole skin, so that it has takea on such a diseased habit, that nothing less thaa the most powerful means will restore its original state. In cases which have not run on to a very chronic state, the other means will prove as effec- tive, and probably should be tried before we should have recourse to the arsenic, although some able practitioners advocate its propriety in almost every case. In the inveterate cases, however, when all other means have failed to produce any salutary effect, its well-regulated exhibition has been fre- quently known to effect the dispersion of the disease. Having determined on its use, we must watch its effects, and persevere so as to give it a fair trial. Fowler's solution of arsenic is the prepa- ration most approved of. It is best to commcnre with the small dose of three drops, to be takeq three times a day in a glass of water; or it may be deemed advisable to use the decoctions of dul- camara, mezereon, or of sarsaparilla as a vehicle, as Dr. Duffin recommends. The dose must not be raised beyond eight drops three times a day, or at the very highest ten. When it first affects the system, the pulse becomes quickened, smaller, and hard; and there arises a prickly soreness about the eyelids, accompanied by some puffy swelling, particularly of the lower one. The gastric symp- toms which are the signals for suspending its exhibition, are, sickness of the stomach, griping pains all over the abdomen, headach and whitish tongue, with a peculiar taste in the mouth. When there comes on a pain in the chest, accompanied with anxiety of the prsecordia, and a certain con- sciousness of serious constitutional disturbance, which is indicated by uncommon gravity of the countenance, the medicine has been either given in too large dqses or continued too long. When the pain in the chest and any of the latter symp- toms occur shortly after its commencement, it is probably a case which will not bear its adminis- tration at all, and other means should at once he substituted. It will generally be found that an impression has been made on the disease when Us effects are recognised in the constitution, and often before this. At first the patches become LEPRA. 133 less indolent, and a long-unaccustomed sensation of heat and activity is felt; the scales first clear off in the centre, (for in those inveterate cases the whole patch is overgrown with scales;) by degrees the circular eminences sink and clean ; and thus a disease which had become engrafted on the habit for years, retires under the influence of this powerful medicine. [Of late, a solution of arseniate of soda, the iodide of arsenic, and an iodide of arsenic and rae>cury, under the form of the liquor arsenici et hydrargyri iodidi, or " Donovan's solution," as it has been called from its proposer, have been used with advantage.] Some of the favourable symptoms ought to show themselves by the time that the medicine has affected the pulse, or when the stiffness and puffiness are perceptible under the eyelids. If the skin do not discover its action when these characteristic signs appear, there is no necessity, —indeed it would be improper,—to continue its use. In others, nausea and loss of appetite, with some epigastric soreness and oppression, are the first signs of its operation ; but we should not consider these latter symptoms as unequivocal reasons for laying aside its use altogether; a few days' intermission will often remove this gastric disorder, when a further trial may be made; and it has frequently happened that the good effects have begun to show themselves soon after its being resumed. But in deciding how far it may be pushed, the discretion and tact of the practi- tioner must guide him : we only wish to lay down as a principle that the arsenic is not so un- safe a means in judicious hands as it has been vulgarly thought; and that after its use is com- menced, ill-grounded fears should not deprive the patient of the steady trial of a remedy which experience has proved to be so valuable. Dr. Duffin states that he has prescribed it in very near four hundred cases, and has never yet seen it do any mischief; and his testimony and that of M. Biett, (two gentlemen who have investigated its effects the most assiduously amongst modern observers,) agree that it is a most important re- medy in this intractable disease. The tincture of cantharides is another very energetic medicine in lepra. It was brought into notice by the eulogy of Mead, although it is nearly certain that it was against the tubercular elephantiasis that he employed it. (Medical Worjts of Richard Mead, M. D. Dublin, 1767; of the Leprosy, p. 455.) However that may be, it has been used ever since in the scaly disease, and it has been found of great effect, particularly of late years. It is applicable in the same invete- rate description of cases as the arsenic, and re- quires quite as much caution in its administration. Four or five drops three times a day should be the utmost dose for the first month of its use, and at the same time the patient should use demul- cent drinks of gruel, barley-water, flax-seed tea, &c. When given at an improper stage, or in too large a dose, it is very prone to produce serious disturbances in the alimentary canal and the genito-urinary organs, so that when we perceive painful heat at the epigastrium, vomiting and purging, or stranguary and erections to follow its Use, it must of course be intermitted ; but unless these symptoms show an unusual degree of vio- lence, it may be often advantageously resumed. By a cautious gradation of the dose, (very small at first,) and the use of the demulcent drinks, with an occasional dose of purgative medicine, those sinister consequences may in general be avoided. In some remarks on the use of tincture of can- tharides in hooping-cough by Dr. Graves, in the fourth number of the Dublin Journal of Medical and Chemical Science, Dr. G. states that it pro- duces its good effects without causing urinary irritation when given in the formula recommended by Dr. Beatty, which we here subjoin:—R Tinct. cinchona composite ^v; tinct. cantharidis; tinct. opii camphorse, ia. ^ss. M. There is nothing in the other ingredients of this mixture which should preclude its trial in lepra; and it would be very desirable if this combination would allow of its free use, by averting its ill effects on the urinary organs. Bateman's disparaging notice of cantharides kept it out of use for some time; but its value has been confirmed by the experience of the Hopital St. Louis, where it is esteemed as only second to arsenic in the chronic cases. Where either of these two remedies is found to create constitutional disorder forbidding its conti- nuance, it may advantageously be replaced by the other : but we repeat, to derive good effects from either of them, the greatest care must be taken to use them in the proper stages; for if they be given whilst any activity of inflammatory action remains, instead of benefit we must only expect to aggravate the whole disease. A course of purgatives is at the present time a favourite practice in the less severe cases of lepra with some French practitioners, who speak with much applause of the good effects of calomel, jalap, sulphate of magnesia, and of soda, aloes, &c. in its removal. We rather suspect that this may arise from the novel introduction of cathar- tics into their practice, and the reaction in their favour which naturally follows on the apprehen- sion and horror they had of this valuable class of ! medicines up to a recent period. It is, doubtless, of the highest importance to keep the bowels free I by the occasional use of laxatives; and for this I purpose a few grains of calomel will be generally found the most suitable. Much purging, how- I ever, as far as our experience goes, is decidedly l injurious, excepting probably in children, where ! we can have recourse to scarcely any other class of remedies, and where purgatives answer very j safely and conveniently. The external and internal means of treatment l have been noticed separately for the sake of ar- rangement, but in practice they are almost always I employed together; and, when judiciously com- bined, they mutually assist each other's action. ! The tepid bath may be used in almost every plan j of treatment, and will be found a useful adjunct. I In those cases which have not spread extensively nor lasted long, the treatment should be com- menced by an abstraction of blood, which is to be repeated either generally or by leeches, whenever the inflammation shows any signs of having re- sumed an active state: at the same time the patient should use some one of the internal remedies, and probably daily the bath. With those it will be 134 LEUCORRHCEA. often judged advisable to apply some of the un- guents or lotions already mentioned, so as to con- join the operation of the different classes of reme- dies ; and it is in such cases that this combination is most effective. In the inveterate cases, our re- liance must be placed in the steady use of the internal medicines. We can go no farther on these points; each particular case will doubtless present its peculiarities, which must be considered. Having adverted to the most approved principles, and mentioned the remedies whose virtues have been best confirmed by experience, it remains for the judgment of the practitioner to guide him in each particular instance in the application of the former, and the choice and conjunction of the latter. [A thorough change of the diet and regimen to which the patient has been accustomed, as well as of all the influences surrounding him, by travelling, is advisable, whenever it is practicable ; and this has been, perhaps, the main agency, when a visit to sulphurous springs has effected a cure in rebellious cases: at the same time, as be- fore remarked, the sulphur has doubtless been an important adjunct.] j HouGHTON. LEUCORRHCEA, from XwkDs, albus, and t>iu>, fluo. Properly, this name ought to be restricted to a white vaginal discharge, but every sort of dis- charge, not sanguineous or menstrual, has been at various times considered as leucorrhcea, whether mucous, serous, purulent, or of a mixed description. Besides " leucorrhoza" and " vaginal discharge," this complaint has been called "fluor albus," "fluor muliebris," " Ies fleurs blanches," "sexual weukness," or " a weakness," and, vulgarly, «the whites." All these are more or less objectionable, and the one chosen for the title of this article as much so as any other; but it is one which is so well known and universal, that it can scarcely lead to error in practice, and is, therefore, the most convenient. It would, no doubt, be very useful in practice to discriminate between the dif- ferent discharges, because very frequently their character will depend upon, and therefore be a guide to the knowledge of, the nature of the dis- ease which produces them, or the particular part which has become disordered or disorganized. Sir Charles M. Clarke has classed the diseases of the female genital organs by the nature of the vaginal discharges which are peculiar to them; and although there are many serious objections to such a mode of classification, yet it proves how important it is to note their several and distin- guishing peculiarities. Of the diseases to which females are liable, there is none more common than vaginal discharge, of one sort or another; it attends most of the uterine diseases, and it is extremely common as the result of either local or constitutional disturbance, or of general debility. It is looked upon by the patients themselves as the cause of ill health, or of the symptoms under which they may happen to labour; whereas, in the majority of instances, the discharge itself can only be considered as a symptom, the effect and result of local or general disorder. By prac- titioners in general, vaginal discharges have been carelessly attended to; there has been one com- mon routine of treatment, without investigation; and it is only when the complaint has been obsti- nate, that at a later period more minute inquiry has been made, and more rational and scientific plans adopted. So many of the vaginal discharges depend upon uterine disorganization, or some alte- ration in the position of that organ, that it is ad- visable in every case, where possible, to make a minute examination per vaginam, so as to ascer- tain the exact condition. It is foreign to this article to enter upon the question of the numerous uterine diseases which give rise to vaginal dis- charges ; we must here only consider idiopathic leucorrhcea, a simple vaginal discharge, uncon- nected with any alteration of structure. The simplest form of leucorrhcea is a mere in- crease of the natural secretion from the mucous membrane of the vagina. As this membrane is continued to the interior of the uterus and the fallopian tubes, it is easy to suppose that now and then the lining of these organs may become affected, and the leucorrhcea have a more exten- sive seat. Frank has mentioned a case of unusual obstinacy, where, after death, the fallopian tubes were found to be the origin of the disorder; and numerous cases are on record, where, in prolapsus uteri, the leucorrhoeal discharge was found to pro- ceed from the os uteri itself. By many of the older writers, it was thought to be merely a variety of menstrual discharge, and hence the term " men- strua alba," &c. Hoffmann, Cullen, and others, considered that the discharge issued from the same vessels which secreted the menstrual fluid in their healthy condition. Dr. Jewel, in his recent work on this disease, states his impression to be, that it seldom issues from the uterine cavity, and proposes a test to ascertain that point in individual cases. Dr. Jewel assumes, that in the night-time, when in bed, the discharge from the interior of the uterus is suspended, which is not the case when it arises only from the vagina or the cervix uteri; and hence he advises that a piece of sponge be introduced into the vagina at bed-time, and if the uterus only is affected, the sponge will be withdrawn dry in the morning. The accuracy of this test must depend upon the assumption being correct. [When it takes place from the uterus, it occurs, according to M. C. A. Tott, (Art. Leucorrhcea, in Most's Encyclopad. der gesammten Medicin.und Chirurgisch. Praxis, Leipz., 1836,) more inter- mittently, and is accompanied by clots of blood and mucus, or by pain in the uterus. It, moreover, aug- ments before and after each menstrual period, and is accompanied by more constitutional suffering.] This is, however, by far the most common form of the complaint, which takes place from the vagina alone, or, perhaps, as this gentleman states, from the cervix uteri. There is an altered action of the mucous lining of the parts, and in what that particularly consists, depends the peculiarity of the cases. It has been by far too common to con- sider all such cases as arising from debility, local as we)l as constitutional, and hence the remedies have most frequently been merely strengthening. In general, we shall find great symptoms of de- bu LTT"?1^ lonS-continued leucorrhcea, a^ not t y W "ea/'y a,WayS the ^sequence and not the cause of the disease. It j8 the ac- knowledged fact, that whenever the general heal* LEUCORRHCEA. 135 has been broken down, and much constitutional weakness occasioned, local disorder is often the result, and such disorder may attack the uterine organs or vaginal passage, though it is not debility which affects them, but through debility a diseased action arises. This diseased action is sometimes acute inflammation ; in others, and more com- monly, sub-acute; whilst, in chronic cases of long standing, a relaxed condition of the secretion apparatus may take place from habit, as we see in the diseased discharges from other sources; this Dr. Dewees has called the " leucorrhcea of habit." Besides inflammatory action, a very large proportion of cases of leucorrhcea depend appa- rently upon irritation, different from inflammation, and yet easily running on into it — a state easily recognised, but difficult to be described. The irritation which excites leucorrhcea is very often remote from the vaginal membrane itself, so that, upon alleviating or removing the distant irritating cause, the complaint will cease. The discharge of simple leucorrhcea is mucous— merely an increase of the natural moisture of the part; it becomes more abundant than in health, but retains its character of mucus, being clear, transparent, colourless, and glutinous to the touch, j This rarely goes on to a great extent without ! being altered in its appearance, and much more , watery. In general, this sort of discharge is ac- companied with but moderate symptoms, is more gradual in its progress, and is unattended by pain; there is little or no inflammatory action present, j [It has, indeed, in moderation, according to Dr. j Simpson, (Tweedie's Library of Medicine, iii. ; 314,) been regarded as an indication of the general vigour and activity of the organs of generation.] In other cases, the discharge is whitish and opaque, becoming creamy when rubbed between the fingers, and rendering water turbid. This sort of discharge has been considered by Sir C. M. Clarke, and others, to depend chiefly on an inflamed condition of the cervix uteri; it is rarely abundant, but occasions much disorder of health, and local pain. A watery discharge, resembling serum, is a very common result of more acute inflammatory action in the mucous surface, and in general appears suddenly, as the effect of cold or any active ex- citement. It occasionally becomes very abundant, is attended with much local heat and soreness, and soon becomes puriferm, or mixed with puru- lent matter, and sometimes with bloody streaks. When it is fetid, brown, or coming away in vio- j lent gushes, organic disease of the uterus is to be feared, the nature of which can only be detected | by an examination per vaginam. Purulent dis- charge from inflammatory action may also take place from the vagina, independent of gonorrhoea from impure connection; and this may be said to J form one variety of leucorrhcea, as, although it may often arise from organic disease of the uterus, it is not unfrequently met with in a perfectly ] healthy condition of that organ. Many will hesi- | tate, perhaps, to class either the watery or the purulent discharge under the term leucorrhcea; hut it is quite certain that all the above-mentioned discharges arise from the mucous surface of the ' vagina alone, without organic disease, and solely i from a diseased condition of the natural secretion I of the part. ' Patients, in general, content themselves with stating the existence of a weakness; and too many medical men are satisfied with such a slight description, and neglect to inform themselves more accurately of the nature of the discharge. The symptoms vary, as will be supposed, and there is a marked connection, in general, between the symptoms and the character of the discharge. The mildest form of the disease is often of long standing before a practitioner is consulted : it is generally found that it has been preceded by what is called " delicate health." The countenance is pale and sallow; the frame weak; the pulse fee- ble, and easily quickened by the least exertion ; the appetite impaired or capricious: the spirits are languid, and exercise is taken with difficulty ; menstruation is either scanty, or too profuse ; the digestion is disordered, and the bowels are irregu- lar : there is pain in the back when the individual is fatigued, or when she remains long in the erect posture ; but it is a pain of debility, relieved by rest, and not permanent. The discharge, which has been referred to weakness, is a disordered action of the mucous membrane, and is the effect of a state of indifferent health. The discharge, in these cases, is mucous only ; is never very abundant, and is unattended by local pain, except in the back. It may easily be altered in character, and then the symptoms are also changed ; as in such cases a very slight cause will increase the disordered local action. The most acute form of leucorrhcea is most commonly the effect of cold, of metastatis, or of some local, irritating cause, and consists of a pro- fuse watery or purulent discharge, accompanied with local soreness and pain. The vagina is hot, very tender to the touch; there is much fever, heat of skin, quickness of pulse : these symptoms being often preceded by a distinct rigor. When the discharge is more scanty and glairy, like the white of an egg, or creamy and opaque, the cer- vix uteri is considered to be principally affected, and may be felt by the finger to be hot and tumid, the pulsation of the minute arteries being easily distinguished. In these cases there is much pain of the back, extending round the hips and down the thighs, and, though relieved, not removed by the recumbent posture. This description of leu- corrhoea may occur in the most debilitated or in the most healthy frames, and may be considered accidental. All of these forms may end in chronic leucorrhcea, where the discharge is more or less profuse and constant, mucous or purulent, or a mixture of both : it may become green and offen- sive, and yet be the result only of functional dis- order. The quantity poured out is sometimes very abundant, even to the extent of a pint and a half in the twenty-four hours; it will then be expelled in gushes on any change of posture. There is in these cases a very relaxed vagina, often accompanied by prolapsus of the uterus : the mucous surface appears smooth and glossy, and has lost its natural rugse; there is great ema- ciation and debility : the eyes are hollow; the face pale or chlorotic; the pulse feeble and rapid; the feet often anasarcous ; the respiration short and laboured, to which succeed palpitation of the heart, dragging pain in the back, inability to ex- ertion, profuse nocturnal perspirations. Unless 136 LEUCORRHCEA. remedial measures be successful, after a protracted scene of much general suffering, the patient dies, exhausted. The causes of leucorrhcea are either those which induce inflammation of the parts or irritation, or which weaken the action of the secreting vessels, although by far too much stress was formerly laid upon the latter. Catching cold, as it is commonly termed, is a very frequent cause of the acute leu- corrhcea ; so also is metastasis of a discharge from some other part, though of a different character. The suppression of the menses, the repelling of milk in the breasts, the sudden checking of catarrh, and perhaps any sudden check to the perspiration, may be considered as causes of acute leucorrhcea: a severe labour, in which the vagina has been kept long upon the stretch, or where it has been injured by officious manual interference, or the use of instruments, will often cause the inflammatory leucorrhcea. Violent exercise, par- ticularly dancing, or riding on horseback, the excessive use of venery, or pollution, have the same effect. Of the irritating causes, we may mention local displacements of the uterus, espe- cially prolapsus; local tumours of the vagina or uterus, and, of the latter, polypus in particular ; stone in the bladder, disease of the urethra, a loaded state of the rectum, the presence of hard scybala, or of ascarides. A pregnant uterus may act in this manner, and also by the increased local determination of blood which pregnancy produces. The impaction of a pessary, or of a piece of sponge introduced for other purposes into the vagina, has sometimes been the unsuspected cause of a long-standing leucorrhcea. [Hence, it is all- important, in obstinate cases, to make an examina- tion per vaginam.] Of the debilitating causes, may be mentioned frequent child-bearing, repeated abortions, profuse menstruation, and, in general, all the usual tendencies to disordered health, such as hot rooms, luxurious habits, indolence, poverty of living, protracted lactation, over-exertion, &c. Treatment. — It is in this point that the greatest errors have prevailed, from the disposition to follow carelessly an established routine. As- tringent tonics—bark and acid for instance, are prescribed in the majority of cases, and perhaps an astringent injection, which would aggravate many of the forms of leucorrhcea we have been mentioning. The plan of treatment ought to be regulated solely by the character of the complaint It must be recollected that it is not always safe to check suddenly a long-standing leucorrhcea, if profuse. Many instances are on record of mischief resulting from such a course, and the following case is a striking illustration. We were consulted by a soldier's widow, several years ago, for a com- plete prolapsus of the uterus, produced by violent exertion during the retreat from Corunna, within a few days of her confinement, and which had never been reduced. There was profuse semi- purulent discharge from the inverted vagina. After some difficulty, the uterus was replaced within the pelvis, and a pessary worn, consisting of sponge soaked in an astringent lotion. The discharge from the vagina ceased ; and in twenty- four hours a quantity of muco-purulent fluid began to be copiously expectorated from the bronchial membrane, which amounted, after a few days, to nearly three pints in the twenty-four houw; in less than a fortnight from the replaceme the uterus, the patient sank from exhaustion. M In the leucorrhcea from constitutional debility or disordered health, of the first class describe, the usual remedies for restoring the vigour of*the frame are required. Tonics of every descrfp* are admissible, according to the circumstancee'C the case; but those containing or combined with the mineral acids have most efficacy. The vege- table bitters, or the sulphate of quinine or the bail itself, may be given three times a-day, combined with from ten to twenty drops of the diluted rak phuric acid, or double that quantity of the old vitriolic elixir. From one to two grains of the sulphate of zinc, or any of the preparations (if iron, will often agree exceedingly well, and as the health improves, the discharge becomes less and less abundant; the diet should be nourishing, the air good and occasionally changed. Besides these remedies, the shower-bath or cold bathing may be used, and especially hip-bathing, or sponging the back and loins freely with cold vinegar and water or salt water. Local remedies are rarely required in these milder cases. In the acute form of the complaint, it is often necessary to apply leeches to the neighbourhood, to the groins, labia, or back; and if the cervix uteri is particularly affected, to the os uteri itself, by means of a proper tube. This is much more easily effected than is supposed, and the liability of the leech remaining at the lower end of the tube instead of crawling up to fasten upon the uterus, may be prevented by in- serting a piston to push the leech higher up the tube. Bleeding from the arm is rarely necessary, though in plethoric habits it may now and then 1 be desirable. A low diet, perfect rest, and anti- 1 phlogistic general treatment are necessary; the bowels should be kept fairly open with saline pur- gatives or castor oil, avoiding aloes, scammony, or others of a drastic character; warm hip-bathing is very useful, and injections into the vagina of warm water, decoction of poppies, or solutions of the super-acetate of lead. Dr. Jewel advises, very confidently, weak solutions of the nitrate of silver as injections, in the proportion of one to three grains of the salt to an ounce of distilled water, j or even the application of the caustic itself to the cervix uteri. We doubt, however, whether this treatment is applicable to this very acute form of the disease. j When more chronic, when there may be said to be subacute inflammation only present, or per- haps only irritation, the general health must be attended to, according to the nature of the gene- ral symptoms ; but in such cases the greatest ben- efit will arise from local treatment, or from reme- dies more especially directed to the local mischiet It is this form of the disease which is most obsti- nate, and for which it is advantageous to possess a variety of remedial measures. Of the internal medicines which have been found serviceable, the balsams, particularly the copaiba, have been men- tioned ; but their efficacy is not nearly so marked as in the gleet or gonorrhoea of the male: the cul>eb8 has also much about the same remedial powers. The cicuta has been found of service by some practitioners. The tincture of cantha- rides has been perhaps more successful, pushed to LEUCORRHCEA. 137 M large a dose as can be borne without producing irritation of the bladder. Astringent medicines are also found occasionally serviceable, particularly the mineral acids with the infusion of roses and alum ; the latter may be given in doses of from five to twenty grains three times a-day. The ace- tate of lead has been often successful, catechu, kino, uva ursi, powder of galls, which may be given in large doses. At the Lock Hospital, Mr. R. B. Walker is in the habit of giving ten to twenty grains of the latter in decoction of tormen- tilla. Dr. Copland recommends small doses of the sulphate of copper. Emetics are said to have been of use, but perhaps in the more acute form of the complaint. The local remedies, however, are most to be depended upon in these cases, and may be applied freely and several times a-day, either by means of the female syringe, or of a piece of sponge or lint introduced carefully into the vagina, and occasionally withdrawn for a fresh supply of lotion. Most of the female syringes are too small, and produce irritation by the fre- quent necessity for withdrawing the pipe for the purpose of refilling the instrument. The writer has been in the habit of obviating the inconve- nience by a gum-elastic tube of three to four inches in length, and about half an inch in diameter, perforated with several holes at the apex, which is rounded off, and the tube made to fit to the stomach or lavement pumps, which are now so common: in this way any quantity of fluid may be injected into the vagina without withdrawing the tube. The applications may be classed into the irritating, the sedative, and the simple astrin- gent ; and as a general rule, it may be stated that the first are most applicable to the chronic states of subacute inflammation, rousing the vessels into a more healthy action. These consist of solutions of nitrate of silver (as just mentioned), of the sulphate of copper, of oxymuriate of mercury, &c.; inunctions of mercurial ointment, fumiga- tions of cinnabar, or the local application of co- paiba or turpentine. Dr. Jewel limits his lotions to the strength of three grains to an ounce of water, preferring the application of the lunar caustic itself to a stronger solution; but at the Lock Hospital, solutions of the strength of half a drachm, or even two scruples to the ounce, are not unfrequently employed. [Dr. Huston, of Phila- delphia, has seen more advantage from injections of the oil of turpentine, than from any other: 01. Tereb. f.sji. mucilag. Acacise, aquae aa f.^iss.] The sedative injections consist of decoction of poppies, of solutions of opium or belladonna, and of the superacetate of lead, the last being by far the most efficacious. The writer is in the habit of using the common Goulard's extract in the proportion of two or three drachms to the pint of distilled or rain water, warm or cold according to the sensations of the patient, and he prefers as much as half a pint to a pint to be used at a time, three or four times a day. The sedative lotions are most serviceable where there is an acrid dis- charge, with heat and excoriation, or where there is much inflammatory action with local pain. In some severe cases he has seen benefit from intro- ducing a piece of lint soaked in a liniment con- sisting of equal parts of Goulard's extract, Bat- tley's laudanum, and mucilage. The astringent Vol. III.—18 ** injections are applicable to the cases which appear to be attended by great relaxation of the vagina and its mucous membrane, with chronic discharge of a mucopurulent or simply thin mucous cha- racter. All the vegetable astringents are then oc- casionally serviceable, as well as the mineral. Alum, the sulphate of zinc, iron, or copper; the acetate of zinc; decoctions or infusions of oak- bark, galls, green tea, kino, catechu, rose-leaves, &c, may be alternately used, or some may be combined together ; but a great deal depends upon their being used freely and frequently. In using astringent injections, particularly alum, it is ad- visable to wash out the vagina directly afterwards with cold water, as the discharge will sometimes become coagulated, and, remaining in the vagina, produce irritation and an increase of the symp- toms. Leucorrhcea has been said now and then to be owing to want of cleanliness, and no doubt this may cause it, but it would be difficult to prove that no other cause existed. The remedy is ob- vious. When there is reason to believe that the leucor- rhcea depends upon a loaded state of the rectum or the presence of ascarides, a soap or a turpen- tine clyster will readily remove both cause and effect. In the leucorrhcea of pregnancy, more caution is to be observed. In the early months it is desirable to check it, as an excess of it will be very likely to bring on abortion; but it must be done gradually, and the lead injections are the safest. Where the discharge arises principally from the uterus, conception rarely takes place ; and when it has occurred, the ovum is easily sepa- rated by the slightest causes, so that extreme quiet is always necessary for the first few weeks. In the latter months of pregnancy, leucorrhcea may be looked upon rather as a relief, unless excessive; the pressure of the gravid uterus and the greater determination of blood to the neighbourhood fre- quently producing symptoms of heat, weight, and discomfort, which are alleviated by the escape of the discharge. Rest and cooling laxatives, with a spare diet, are generally all that will be required. [Uterine leucorrhcea is by no means as much benefited by astringent injections as the vagi- nal. It would appear, indeed, that, at times, they cause great irritation, and an aggravation of the local distress. The acute form requires cupping on the loins, with the hip-bath, and warm emollient injections into the vagina and rectum; and, after the active stage has passed away—or at any time, in the chronic form—counter-irritants may be ap- plied to the sacrum, as the ointment of tartrate of antimony and potassa, croton oil, or dry cups. If a blister be applied, it ought not to be kept on too long, and its surface should be covered with tissue- paper, to prevent, if possible, the absorption of the flies or of their active principle. The same inter- nal remedies, directed to the special pathological condition of the frame, are needed as in vaginal leucorrhcea. Of late, it has been affirmed that ergot has succeeded where other remedies had failed, in both the uterine and vaginal variety. It may be given in the dose of five grains three times a day.] Very young children are liable to leucorrhcea. It occasionally occurs in infants shortly after birth; in these cases it is more or less purulent, and at- 13e LEUCORRHCEA. of the vagina. It s very apt to occur also during i is ardor urin®, wnicn uue Rut how »«» dentition,°and not only when the first set of teeth rhcea, unless ^""i""^^^,™* are in progress, but at the time of the second set, to distinguish in a "" ^o™" "J,"^^ and even when the dentes sapienti* are irritating | leucorrhcEa, or where a gonorrhoea is not^recent, the system at a more mature age. Young girls are also sometimes affected with leucorrhcea, at- tended with debility, disordered health, and pain in the back. This usually arises from intestinal irritation or from gravel, though probably the lat- ter may be equally the effect of the visceral disor- der. It must be borne in mind that the appear- ances above described are not unfrequently the effects of improper habits. The curative measures are simple; the portion of the vagina affected is usually very limited, generally near the external orifice, so that the Goulard lotion is readily and effectually applied. Alkalies and gentle purgatives with a mild diet and rest, will in most cases be sufficient to remove the complaint. An epidemic vaginal catarrh has occasionally existed, as men The redness and tumefaction of the labia, nymphe, &c. only can be seen in a recent gonorrhoea, and they may be seen in severe cases of leucorrhcea, particularly in those following local irritation,.et possessing more acute inflammatory action. One other test is mentioned by authors, that in leuoor- rhcea the discharge ceases during menstruation, but does not in gonorrhoea. This, however, is denied by other authors, and, as Dr. Jewel ob- serves, " this is a point which cannot easily be decided, as from the colour of the menstrual se- cretion, that of the leucorrhceal or gonorrhoea! must necessarily be in a great measure obliterated." From what has been stated, it is quite evident that it is extremely difficult to distinguish between the two diseases, and particularly when we recol- tioned by Professor Capuron to have prevailed in j lect how ready the party in fault will be to con- Paris. It has also been observed in this country among children, but attended by much local in- flammation and constitutional disturbance of a typhoid character, and which, unless treated very early, has ended in ulceration, sloughing of the pudenda, and death. These cases have been de- scribed by Dr. Percival of Manchester, as having occurred there in 1791. Again, in 1815, the at- tention of the profession was called to them by Mr. Kinder Wood, who had then seen twelve of them, all occurring at Oldham, or the immediate neighbourhood of Manchester. Dr. Mackintosh, of Edinburgh, has described four cases, of which two followed immediately after measles; and it is not uncommon to find a milder sort of leucorrhcea making its appearance after the subsidence of that eruptive disease. Except those mentioned by Dr. Mackintosh, it is curious that nearly all the others have been noticed in the neighbourhood of Man- chester ; for Dr. Ferriar, who practised there also, states, in his " Medical Histories and Reflections," that he had "met with several instances" of a similar nature. The cases related by Dr. Percival are important on another ground, as the first in- stance which fell under his notice led to the com- mittal of a youth for a supposed rape, the appear- ances on the pudenda of the child having fed to the suspicion that violence had been committed. The rapid occurrence of several similar cases alone saved the youth from trial and probably execution. The recollection of such facts is of real conse- quence when an opinion is required upon sup- posed instances of defloration. There is one material point connected with cases of leucorrhcea, and especially those where the discharge is purulent or of an acrid character. In such instances it is well known that sexual in. tercourse will often bring on a train of symptoms very much resembling gonorrhoea in the male. This, when occurring between husband and wife, has often led to much domestic unhappiness, from the supposition of one party or the other having contracted gonorrhoea from impure connection. It is important to be able to distinguish between gonorrhoea and common leucorrhcea to remove or confirm the suspicions, but it is very doubtful ceal or distort the facts. In all such cases it be- comes the duty of the medical man to give his assistance not only in curing the disease, but in preserving domestic harmony. q locock LICHEN, Xti^ijv. The cutaneous affection known formerly under this term was supposed to be, with several others, a mere modification or symptom of the lepra Gra?corum (about which disease we have seen what confusion reigned—see Lepra); and we find that this improper notion was still held by writers at the beginning of the last century. It was also erroneously represented to be synonymous with impetigo. All this origi- nated in its not being quite clear what was intended by the term Xti^ijv in the Hippocratic writings, and in a misconception of Celsus. The latter describes under the name of papulae, a form of cutaneous eruption which the best authorities consider to be the same as the \cix>iv of Hippocrates, and it is quite evident that he means a perfectly different disease by the term impetigo. Able commentators assert that the Xci^iji'ts of Hippocrates (Aphorius. sect. iii. aph. 20,) signify what they denominate " pustule sicca?,"—an expression which accords in sense with the papula? of Celsus, and the same term (or pimple) which is adopted in modem nomenclature from the Roman author. Since the time of Willan, indeed, his application of lichen has been in universal acceptation, and it now al- ways signifies an eruption of small, solid, reddish. papula?, which terminate with a scurf, and are very liable to recur. The papula? of lichen usually occur in adults, and are often connected with internal disorder, but not so exclusively as to be admitted into the dd- nition: they are accompanied always with more or less pruritus, and are situated on the arms, face, or legs, and sometimes are developed all over the body. But the closer description of the disease and its course requires that we notice its varieties; and here we may remark that we differ from those authors who deny the utility of entering into more minute distinctions than are necessary merely to denote the generic relations of the cutaneous whether any very accurate diagnosis can be formed. , affections. It is true that multiplying telml u*- LICHEN. 139 . kssly would only tend to embarrass the student ;,^f those diseases; but it is equally certain that classifying phenomena according to the various ^.relations of form, colour, situation, extent, and t:3ther conditions, and thereby establishing real va- -rieties, not only is highly conducive to the advance- ment of the pathology of those affections, but very much facilitates the attainment of a practical ac- quaintance with them. It appears to us to be as in- dispensable to the study as it is to the description ^of them, to have specified varieties fixed in the mind ,vby distinctive appellations ; and we confidently ^affirm that students who were really interested in acquiring a knowledge of skin-diseases have ever found material aid from the division into species "accomplished by Willan. Their imperfections are, of course, manifold, but it is a proof of their utility to observe that every systematic writer, whatever his sentiments be with regard to them, whether he admire them or call for their abroga- tion, is obliged to notice them. The fact is, that "they burden the memory of those only who make the vain endeavour to learn skin-diseases by books, while they assist in a very efficacious and pleasing manner the labours of the patient observer of nature. The principal species, or rather varieties, of this •'affection are the following. 1. Lichen Simplex.—This is the species most commonly met with. It consists of small red papula?, more or less elevated and acuminated, 'which contain no fluid of any kind, and are quite 'opaque and solid. It mostly commences on the -face and the back of the hands, and, when more generally extended, it affects in preference the posterior and exterior parts of the arms and thighs. -It may be stated generally, that it occurs most frequently in those parts of the skin which are most delicate and exposed to external influences. •The eruption of papula? is accompanied with a >. tingling formication, which is very disagreeable, particularly during the night, or when the person becomes heated by exercise or otherwise. This variety is either acute or chronic in its course and character, but much oftener the latter. In the acute form the papula? are very red, and rthe inflammatory action accompanied with much heat and itching. After three or four days their redness diminishes, and having thrown off a mi- • nute furfuraceous scurf, they disappear. They are, i however, at the same time followed by others. In about a fortnight after four or five successive erup- i tions, it generally subsides altogether. This acute ; form of the affection mostly occurs on the face and trunk. The chronic form is generally situated on the limbs, and prefers, as before mentioned, the pos- terior and exterior surface of these. The papula? have scarcely any inflammatory character, and the pruritus with which their manifestation is preceded or accompanied gives but trifling annoyance.— While some are sufficiently red, it requires that we pass the fingers over the great majority which stud the surface to distinguish them, so little do they differ from the rest of the skin in colour. The papula? remain from a week to a fortnight, and leave the branny desquamation behind on waning ; but the duration of the affection in the chronic form is quite indefinite, as fresh successive crops of pimples protract it often to many months. It manifests its tenacity sometimes by breaking out in a different part of the body after disappearing from its original situation, and it is liable to recur from the slightest cause, when the patient thinks that he is at length clear of it; such as changes of weather, errors in diet, or unusual exercise. 2. Lichen circumscripta.—This variety is dis- tinguished by a marked peculiarity of form. The papulse, which in the former species are scattered without order, assume in this a circular arrange- ment. At the first view nothing may be observed beyond a ring of red papula?, but on closer inspec- tion these are found to inclose areas covered with a minute farinaceous desquamation, which is de- tached from small papular eminences beneath. The external papula? alone manifest any inflam- matory redness, or if those inside the circles differ from the rest of the skin in colour, it is only by a light pinkish hue. The circumferences of these circles, at first so small that the papula? lie clus- tered in contact, soon spread by new eruptions, while the old borders fall into the desquamating centres. They seldom enlarge beyond the size of a shilling, and when the eruption is extensive, they mingle their circumferences, yet not so inti- mately but that it is always easy to recognise their circular form. This variety occurs as frequently on the trunk and face as on the extremities. From its tendency to spread and to propagate by form- ing new patches, it is not to be speedily eradicated. We have observed it occurring most frequently in early youth: it is called by boys at school wildfire. 3. Lichen pilaris.—This differs from the lichen simplex probably in no pathological character save that the papula? are developed at the root of the hairs, which perforate their centres. This variety is remarked to be more chronic in its dura- tion, and to be accompanied with greater irritabil- ity of the skin, than any of the preceding. Bate- man's observation accounts for this: he states that it is often connected with derangement of the digestive organs, produced by ardent spirits. 4. Lichen lividus. — This is a kind which almost always occurs in persons with constitutions broken up by misery and privation. It consists in dark violet pimples scattered here and there on the legs and thighs; they are flat and broad, and are generally mixed with specks, which differ in nothing from purpura, to which disease this form of lichen is evidently allied. It is not so rare as some authors assert, but it is of little importance in a medical point of view, as in most cases its cure is to be promoted rather by the charity than the professional services of the physician. 5. Lichen agrius.—This is the severest form of this disease, as its name implies. ('Xypids, ferus, agrestis.) The papula? are smaller than in the lichen simplex ; they occur in congregated masses, and are very numerous. Their colour is deep red, and the skin where they arise is affected with a vivid erythematous inflammation, which spreads between them and beyond them. The heat or pruritus which accompanies their erup- tion is of the most violent character, and often deprives the patient, night after night, of rest: he cannot avoid scratching the pimples, and often employs a hard brush for this purpose. This pro- 140 LICHEN. - s «fr4nL*""'S srsV-ss tolerable burning and itching, only tends to make matters worse; it aggravates the inflammation, and encourages the development of new patches. Besides this, where the papula? become forcibly abraded, small ulcerations ensue, and a liquid oozes from them which forms thin crusts or scaly con- cretions. In some rare cases the affection appears to be relieved by the discharge, and having soon thrown off the soft incrustation which the latter formed, the cutaneous inflammation and its effects subside. The general course of the disease is, however, very different; painful exacerbations and new eruptions take place for many weeks; and at length it falls into a chronic condition, in which the inflammation nearly ceases, and the pruritus becomes much mitigated. In this condition it remains for an indefinite period, the serous secre- tion being checked, and the scaly crusts becoming dry, and diminished to a farinaceous exfoliation. After a severe attack of this affection the skin remains for a long time thickened and rough, and retains a morbid sensibility, which persists for a considerable space. This aggravated form of lichen is sometimes produced from the lichen simplex by causes, gen- eral or local, which determine a higher inflamma- tory action. In such a case the inconsiderable itching which accompanied the pimples of the original species is changed into a burning pruritus; the papula? become in some places apparently con- fluent, and surrounded with a deep red inflamma- tory areola; and thus it proceeds in the course described. It more generally, however, com- mences as a distinct form, putting on its charac- teristic severity from the very beginning. In that state where the lymphy fluid which exudes from the abraded and ulcerated papula concretes into crusts, it approaches very nearly to the character of eczema. If it persist without showing any tendency to heal, after some time a purulent secre- tion forms, and may become, as Celsus remarked, really converted into impetigo. The situation of this species is uncertain. It occurs with about equal frequency on the face, trunk, and extremities. It is not peculiar to any period of life, as it happens at all times from child- hood to old age; but it appears to be more fre- quently and easily excited in those vitiated habits of body produced by addiction to spirituous liquors. This is more particularly the case among the poor, who, in addition to the injury done by the drinking itself to their organization, deprive them- selves of a wholesome nutrition to indulge this miserable propensity. It is always preceded or accompanied by some fever and gastric derange- ment, sometimes of a serious nature; such as headach, nausea, vomiting, and loss of appetite, also general soreness and pains. Internal disor- der is also very apt to occur if the eruption be re- pelled by the unseasonable application of cold. 6. Lichen urticatus.—This is a variety which well deserves to be separately specified. It con- sists of an eruption of large red papulee, like the wheals produced by the stinging of nettles. They are found on the neck and arms of young persons, and those of a delicate skin, in spring and sum- mer. It disappears with a slight exfoliation after a short time, and recurs again generally several character of the last species, but it gives condftr: able annoyance, particularly at night, when it* is accompanied by a slight feverish access. ^ M. Biett describes a variety distinguishes! neral exaltation of sensibility which the solar hen gives rise to in the torrid zone. It is appropriately called the " prickly heat" in the tropical countries, « The sensations arising from it," says Dr. James Johnson, "are perfectly indescribable, being00* pounded of pricking, itching, tingling, and mtttf other feelings." It is usually, but not invariably, accompanied by an eruption of vivid red pimples, not larger in general than a pin's head, which spread over the breast, arms, thighs, neck, and oc- casionally along the forehead, close to the hair. This eruption often disappears in a great measure when the patient is sitting quiet and the skin is cool; but no sooner does he use any exercise that brings out perspiration, or swallow any warm or stimulating fluid, such as tea, soup, or wine, thai the pimples become elevated, and but too sensibly felt. As would be anticipated, the new comers are much more liable to this unpleasant affection than natives or long residents; for the susceptibil- ity of the skin is greater, while the contrast be- tween the cold and hot climate is still sensibly present; but even natives are not exempt from it The fears which Hillary and Mosely cxpTeBS about dangers accruing to the patient from repulsion of the eruption by cold bathing are ungrounded; bit Dr. Johnson states "that the cold bath rather aggravated than appeased the eruption and tirif ling, especially during the glow which succeeded the immersion." "The only means," says he, "which I ever saw productive,of any good effect till the constitution got assimilated to the climate, were light clothing, temperance in eating and drinking, avoiding all exercise in the heat of the day, open bowels, and, last not least, a determine! resolution to resist, with stoical apathy, (the temptation to scratch,) its first attacks." Mr. Plumbe remarks with justice, «that the prickly heat is not confined to the climates from which it derives its name. In fact, the lichen uriieatut occasionally occurs in these countries with an in- tensity of itching and tingling that must be qoits as tormenting as the tropical affection. Th writer knew a person who for several successiw nights was obliged to jump out of bed from the sudden supervention of an intolerable heat and itching, produced by an eruption of this nature. The pimples which arose on the head in particular produced such irritation, that the patient felt as if they would make him mad. After remaining in the cool air for a while, and taking a draught of water, they subsided, and allowed him to go » sleep at an advanced period of the night, leaving him quite free till the next night It is ofto» LICHEN. 141 „»rought on in spring and autumn, in young per- sons, by violent exercise, and it is a penalty not . unfrequcntly paid for dancing in these seasons. Mr. Plumbe mentions a case where a public per- former was obliged to forego this manner of ob- taining a livelihood from the severity of its at- 'tacks. (Practical Treatise on Diseases of the Skin, p. 251, third edition, 1832.) Diagnosis.—To some of the foregoing varie- ties may be referred every example of lichen ; but these papular eruptions are so manifold, and pass 'so readily into one another, that it may be difficult to assign its proper place to individual cases: 'this, it will be conceived, is not of essential im- portance. Although we have adopted this divi- 'sion into species because we are convinced of its convenience and exactness, and think that it tends to forward the study of cutaneous pathology, yet it is not intended to impose a notion on the stu- 'dent that we derive at present much assistance from them in the treatment. Their diversity con- sists, at least chiefly, in the degree of inflammatory action, and is much influenced by the previous 'constitution of the person, their circumstances and habits, local relations, &c. The causes which produce them afford, also, a proof of their agree- •ment. They may be comprised under two gene- ral heads: — 1st. Heat, either of the atmosphere or artificial. This is a common source of them, from the slightest summer rash (lichen simplex) to the prickly heat. Blacksmiths and glasshouse- men are very constantly affected by some form of it, from the heat of their furnace and forge. 2d. Derangement of the digestive organs, either from ^improper diet and spirituous liquors in excess, or -defective and unwholesome aliment. To this head are often to be traced cases of lichen agrius, lichen urticatus, and to the latter cause particularly the lividus. An accurate diagnosis of lichen is not always easily made. It is of considerable importance in , practice, however, to be able to distinguish it, more indeed for the sake of determining what it is not, than for establishing its own identity. We must be particularly cautious not to confound it with any of the exanthematous eruptions, with measles or scarlatina for instance; but it is only necessary to point out here the possibility of this mistake: if the description of the varieties above given be fixed in the mind, it cannot occur. From scabies, prurigo, and eczema, the lichen simplex is not so easily distinguished. We will observe, in drawing the distinction, that scabies comes out in vesicles which discharge a fluid on breaking, that it occupies the intervals, between the fingers, and the flexures of the wrist and finger phalanges ; on the other hand the solid red papula? of lichen are very different from the trans- parent vesicle of scabies; they are situated, as we have seen, on the exterior parts of the arms and thighs; and if they appear on the hands, where scabies almost universally begins, they occupy the dorsal surface, and do not affect the joints or the intervals of the fingers. The contagion of scabies would settle the question if this were ascertained, but this is never the case where there is a doubt as to the diagnosis. It is, in fact, to procure in- formation as to the contagious nature of the erup- tion under consideration that diagnostic marks are valuable between scabies and lichen, in order that proper precautions may be taken, in case it be the former, to prevent it spreading. Lorry sums up the difference between them with con- ciseness and accuracy. " Primo a scabie differ- unt, quod papula? ilia? (lichenis scil.) vulgo magis conferta? sint et elatiores; 2°. quod rubicunds magis et minus arida? sint; 3°. quod sanatis febri- bus superveniant; 4°. quod latioies sint, et sa?pius recidivam patiantur quam vera et legitima scabies; 5°. quod in furfur abeant notabile; 6°. demum quod remediis sanentur a scabiei curatione alie- nis." (Bateman's Synopsis, note, p. 8.) The papular nature of prurigo comes nearer the external character of lichen simplex, but the pim- ples of the former are larger, much more separated, and seldom differing in colour from the surround- \ ing skin; they are not acuminated as in lichen, and are covered generally with a speck of dark blood: this is produced by abrasion in scratching, the pruritus being of a peculiarly acrimonious na- ture; whereas in lichen simplex it is compara- tively mild. Lichen may simulate eczema so closely as to require much tact and consideration to decide between them. When the eruption of lichen simplex is very vivid, there often appear, here and there, some vesicles; and when with this occurrence it happens that the patient abrades the summits of the papula?, the excoriations give out a fluid which concretes and forms soft crusts; in this state many of the features of eczema are pre- sent. On inquiry it will be ascertained that at first the eruption was entirely papular, and that the few stray vesicles are merely adventitious. They generally come out after the excoriations have been made, and in their immediate neigh- bourhood. The lichen agrius is still more difficult to dis- tinguish from eczema. We must rely on the his- tory of the eruption, and the character of the ele- vation of the skin, which is vesicular in the latter case, and papular in the former. This can gene- rally be determined by examination after the crust which covers it is removed. Besides this, the irri- tation which the real eczema causes is strongly contrasted with the burning itching of the papu- lar eruption; but this distinction may fail after a long duration of the latter disease, and the others become so confounded, that it is often impossible to distinguish between them. It has been already stated that lichen agrius sometimes takes the characters of impetigo, but the reverse never takes place; the latter ought never to be mistaken for the former. The small psydracious pustules of impetigo are manifest from the beginning, and the coarse crusts which form on their breaking are different from the thin layer which the excoriations of lichen furnish. When lichen agrius subsides into a very chro- nic state with a tendency towards cure it is often so much overlaid with furfuraceous exfoliation as to be taken for a scaly disease. Some authors, indeed, assert that it is not uncommon for it and for the lichen simplex to be converted into psoria- sis. The writer has lately seen a gentleman who had on the arms and chest an eruption of lichen simplex, which in the axilla? and the folds of the buttock was changed in character so as to resemble ptyriasis more than any other cutaneous affection. 112 LICHEN. Lichen circumseriptus has often been mistaken for herpes circinnatus ; we have Intely seen a skil- ful observer make this oversight. It is to be borne in mind that the circular patches of the papular eruption are smaller, and show no vestiges of vesi- cles or their remains, which are always discernible on closely inspecting the rings of herpes circinna- tus. Moreover the central space of the latter is quite untouched, but in the lichen the papula? are still recognised, paler than the external circle, and overlaid with the farinaceous scurf. It is proper to remark that the psoriasis guttata has been also mistaken for lichen circumscriptus. The difference between lichen urticatus and tepid bath. Some even prefer the cold bath; the warm bath is too stimulating to the skin, ft coincide with these cooling means, it will be reqgj. site to adopt a diet in which the allowance.* animal food is diminished. It will rarely be nee» sary to inhibit it altogether, but the greater proper. tion that vegetable and farinaceous matters msb in the meals the better. Wine and spirituo,, drinks should be laid aside, but there is no ohjet. tion to a moderate quantity of table-beer. As to medicines, it will be sufficient to give a sebe laxative occasionally, so as to keep the bomb open : sometimes it will be judicious to use a fen grains of calomel or blue pill for this purpose; urticaria will be ever easily recognised by any one potions of lemonade are much used in Fran* Bateman extols the use of dilute sulphuric s*jd where a grateful tonic is called for. For allajuij the itching, various topical applications have been used. Mucilaginous decoctions, as thatiof marsh- mallows, are said to have a soothing effect. A lotion with two drachms of prussic acid to a pint of water has been also recommended highly. We believe that one of the best applications tor tbis purpose is milk of almonds, in the composUifJLof which a few bitter almonds have been mixed rrtiib this the skin should be gently moistened three times a-day, or whenever the pruritus become troublesome. In some of the acute cases where a good deal of fever accompanies the eruption, or where muck sympathy is evinced in the digestive organs by vomiting, loss of appetite, or pain in the head, it will be highly advisable to take away some blood from the arm, and to pursue a more decidedly antiphlogistic plan. Stimulating applications, such as sulphur fumigations, or ointments with camphor, &c. are not to be used in the acute forms; but when much of the activity of the eruption is subsided, and the harsh chronic stale of the skin, mentioned before, supervenes, then baths of the sulphuret of potash or of the sulphu- reous mineral waters will be very proper. In this state the ointment of the proto-ioduret of mercury, mentioned in the article Lepba, has been uses' with decided benefit. In lichen agrius it is advisable to commenced treatment almost always by a venesection. No- thing tends so much to allay the vehemence of the burning pruritus. This practice will be more pointedly indicated if the patient be young ami vigorous, but we consider that it is not less useful in an opposite condition. The application oi leeches in the neighbourhood of the inflamed p«- pula? will also prove a very effectual sedative for the painful itching, but in their use it must be carefully observed to place them exterior to the inflammatory area. Every thing said with respect to the necessity of an antiphlogistic diet is still more indispensable to observe here while any fev« remains, or while the inflammation displays sey activity. Under these conditions, every locat'sti- mulant must be avoided as worse than useless. Emollient poultices, with some Goulard's extract sprinkled in them, will sometimes be found K> assuage the irritation, but if used more than barely lukewarm, they will only increase it. The almond- milk embrocation will answer this end probabtysi well as any other. Dr. Elliotson recommends,* the best means lor allaying the tingling and itching. that has seen both affections. Besides the exan thematous character of the latter, the form is quite distinct. The papula? in the lichen are large, ele- vated, distinct, and are more or less permanent. The wheals of nettle-rash are confluent, flat, and scarcely ever remain beyond a few hours at a time. This lichen may also be mistaken for the venereal eruption called by some authors lichen syphiliticus. The latter disease is marked by its coppery hue; besides it is destitute of the pruritus which accompanies all proper lichens, and it is more steadily persistent than lichen urticatus. Again, it is seldom found alone, almost invariably accompanied by some of the other attendants on . secondary syphilis. Prognosis.—In none of its varieties can lichen be considered as a dangerous disease, and in the less scarce forms almost the only importance that attaches to its presence is the troublesome itching which the pimples occasion. When it arises from merely local or temporary causes, such as the di- rectly irritating action of the spring or summer heat, it is of little consequence and of short dura- tion ; but if its origin be more deeply seated in the constitution, if it be liable to frequent recurrence and exacerbation, it leads to more unpleasant con- sequences. It is in such instances that it gives rise, after a long duration, to a thickened rugous state of the skin, which completely obstructs its function of exhalation. At other times, as we have before stated, under similar circumstances it becomes complicated with eczema and impetigo, and, according to Biett, sometimes degenerates into ecthyma. The lichen agrius, as it is the most severe of all the varieties, so is it also the most difficult of cure ; when situated in the face, it more particularly resists with uncommon obstinacy all therapeutic means. It may be stated as a general rule, that this and the other varieties are difficult of removal in proportion as they are of long dura- tion. Treatment.—In the lighter forms of this erup- tion, the treatment is simple. It demands, indeed, but little interference from the physician. His services here are seldom required further than in making an accurate diagnosis, tracing the eruption to its true cause, and laying down principles of treatment As they generally occur in warm weather, and depend more or less on it, the indi- vidual should keep the house for some time, and thus abstract himself from the direct heat of the sun and from exercise, which last is one of the most common exciting causes of it. It will be useful to employ every day towards evening the LIVER, (DISEASES OF THE) 148 a lotion of chloride of lime or soda, to be used ' very dilute. If under depletory means the eruption loses much of its intensity, then the exhibition of tonics will often prove highly serviceable. The decoction of cinchona with sulphuric acid is preferable to any other. This is especially useful in the cases of broken-down, dissipated subjects, and where ' the constitution has been brought rather low by | antiphlogistic measures. It is not to be imagined that there is any thing contradictory in this prac- tice of first reducing the system by depletory means, and then administering tonics as it were to restore it; on the contrary, the practice is found not only compatible with theory, but experiment- ally good. In fact, where we have to do with im- paired constitutions, the abstraction of blood will be useful, as the tonics will act with greater cer- tainty and efficacy after it, than if they be trusted to without it. With respect to the diet in this stage of the affection, it should be still kept of a very light kind; but it is to be borne in mind, that where the disease has supervened in an individual whose digestive organs and system generally have been greatly impaired by habitual drinking, it is expedient to allow him a small portion of his ac- customed stimulus. This is another fact confirmed by experience and reconcileable to pathological principles. Where it has fallen into an inveterately chronic state, lichen is a very intractable malady. Sulphur fumigations, sulphur and alkaline lotions, have in this case been found beneficial. Mercurial pre- parations have also beten recommended. If obliged to have recourse to this mineral, we would prefer trying the proto-ioduret of mercury to any other preparation, from what is known of its effects in some other cases ; one grain twice a-day is a suf- ficient dose for an adult. With its internal use, might be properly joined the local application of the ointment of the same preparation. We believe, however, that Fowler's arsenical solution is the best internal remedy in those inveterate cases ; it is to be given in doses of from three to eight drops thrice a-day, and continued for at least a month. The cautions usual in its exhibition are of course to be strictly observed. j Houghton. LIVER, DISEASES OF.—The liver, in com- mon with other organs, is liable to certain morbid changes of structure, usually designated "organic disease." The application, however, of the epithet " organic," has been neither very precise nor cor- rect ; for it is used to express every description of alteration, from simple congestive tumefaction to complete disorganization or alteration of structure or tissue. In the present [general] article, we propose to consider the diseases of the liver (hepa- titis excepted) [which will follow in a distinct article] and its membranes, and the general effects of them upon the economy at large. Many of these are purely the effects of inflammatory action of some kind ; many the result of morbid growths or accretions, and present morbid changes of struc- ture, induced by causes the nature and operation of which are not satisfactorily ascertained. These affections may be arranged under two general heads or divisions, namely, those affecting the in- vesting membrane, and those affecting the more immediate substance of the liver. I. Diseases affecting thf. Investing Mem- brane of the Livek. The diseases affecting the investing membrane of the liver are mostly the result of inflammatory action. Inflammation, when confined to the mem- brane, is generally also confined to the anterior or convex covering. Sometimes, however, it occu- pies those portions in contact with the stomach and duodenum. The effect is a layer of coagu- lable lymph. This layer gradually concretes, be- comes more or less organized, and firmly attaches the peritoneal covering of the liver to the conti- guous parts, producing what are termed " adhe- sions." In some cases, the adhesions are so gene- rally diffused over the whole surface, and the contiguous membranes so closely united, as to seem one simple but thickened membrane, nor can the separation be effected without sufficient violence to lacerate the original membranes, and separate them from their natural connections. More frequently, however, these adhesions are formed by membranes of considerable length, in many instances resembling the processes known more commonly as " the ligaments of the liver." The substance of these adventitious membranes varies in different cases ; in some, it is extremely delicate, pellucid, transparent, and beautifully in- terwoven. In others, it is much denser and firmer, and frequently crossed or intersected with strong, inelastic, ligamentous-like bands. The author has now in his possession a membranous connection of this sort, about five inches in depth, and which is traversed on each side by strong unyielding bands of this description, several lines in thickness. In many cases the membranes present no ap- pearance of unusual vascularity; but it not un- frequently happens that the whole surface is covered with minute vessels, intersecting each other in every possible direction. These vessels are sometimes of a bright vermilion, sometimes of a purple colour. In such cases, these adventitious membranes are in a state of inflammation, and give rise to all the local symptoms of severe in- flammation of the contiguous viscus, without the constitutional excitement so invariably accom- panying a true phlegmasia. It may be as well to explain the nature of symptoms which frequently prove embarrassing to the practitioner. These connecting membranes, being of foreign origin and the production of disease, are not so intimately connected with the system as those which are more immediately and essentially parts of the natural organization, and exert no direct in- fluence upon the animal economy. Consequently, when diseased or inflamed, they become mecha- nical sources of impediment, rather than causes of constitutional derangement. Like all other organized parts, they exhibit sensibility and all the other manifestations of vitality, but still the sensibility is probably much inferior to that of the essential organizations ; or, at all events, from their loose connections, and the total absence of all functional contribution, they do not appear capable of influencing the economy, like the other parts, more intimately connected, when labouring under disease. It is obvious that the treatment 144 will consist in mere local measures, such as leech- ing, cupping with scarification, blistering, &c. Dry cupping is often very efficacious in such cases. Sometimes the coats of the liver are converted into cartilage. Dr. Baillie, however, states that this happens much more frequently in the spleen than in the liver. The cartilaginous conversion is generally smooth, thin, and soft in its texture. Sometimes small fat-like excrescences are observed upon the surface of the peritoneal covering. They vary in size, from that of a pin's head to that of a pea. They often partake of the character of tuberculous accretions, and their consistence varies from a mere pulp to a hard fatty mass. They are not important in a practical point of view. II. Diseases or the Liver. The diseases of the liver may be divided into those affecting its immediate structure and those affecting its appendages. Morbid Anatomy of Diseases of Structure.— A very common effect of previous disorder is pre- ternatural evolution of volume from simple tume- faction. It is the consequence of an unnatural accumulation of blood in the vessels of the liver. It is that condition described by the French writers under the term Hypersemia, and may be either general, that is, pervading or occupying uniformly the entire of the organ, or more partial in its extent. When general, the liver presents a degree of redness uniformly diffused throughout. Its volume is considerably enlarged, but of the natural consistence; and its absolute weight, as well as specific gravity, is increased. If an incision be made into a liver in this con- dition, black fluid flows out very abundantly. It often happens, however, that the hyperemia is more partial, appearing in distinct patches, and forming red spots, varying both in figure and ex- tent, in different parts of the liver. These spots are rendered more conspicuous from the contrast presented by the surrounding paler parenchyma. The colour arising from hyperemia will vary ac- cording to circumstances. In some instances it assumes a dull brick red ; but in most cases it is of a reddish purple, which is readily reconcilable with the sources of supply. Andral asserts that hyperemia is of three kinds. The first he considers as arising from irritation, which may be either idiopathic or sympathetic of—" subsequent to" — a similar affection of the alimentary tube. The second description he con- siders to be wholly of a passive nature, the blood accumulating in the parenchyma, exactly as it accumulates in the gums in scurvy. The third kind he looks upon as purely mechanical, arising from obstruction of some description or other in the right side of the heart; «the blood then stag- nates in the supra-hepatic veins, and obstructs the liver." ("Vol. ii. p. 588.) The same authority asserts that « congestion of the liver from a mechanical cause" often takes place in infants during parturition. Such infants have the liver so gorged with blood, that the ves- sels give way, and the blood is extravasated under the investing membranes on the anterior or convex surface. M. Billard states that effusions of blood into the cavity of the abdomen, in consequence of LIVER, (DISEASES OF THE) ""such a turgid condition of the liver, are by* means uncommon. Hy perasmia may be considered as comprehendiij I several distinct varieties, differing as to their sett land nature. It may take place, for example, ia | the larger vessels, producing thaf species aff|» thora more properly designated engorgemenM^ this species the larger arteries and veins SMSpre- ternaturally distended ; and the flow of blood ot section of the substance will be immense, t may also be complicated with a sub-inflammatory condition of the vessels, particularly of the veins. When we consider the peculiar character of the circulation through the liver, and the nature of the vascular structure by which the function of the organ is performed, we can have no great difficult; in understanding the subacute character of the symptoms even of what may be termed the more active diseases of the organ. The function of the liver, contrary to that of most other organs, is performed through a venous rather than an arterial tissue; and hence almost all the diseases of the liver manifest the congestive or the veno-congee- tive character; that is, symptoms are either almost altogether absent, or they are of the more obtuse description. Very often in the congestive affec- tions there is no obvious manifestation of disease, till the liver has acquired a volume incompatible with the spacer naturally assigned for its accom- u}94Jfetion; and the attention of the patient is attracted, not by the primary affection, but by the secondary ones. But when the disease partakes of the nature of veno-congestive inflammation, then we find those subacute? symptoms character* istic of this species of inflammatory action; such as dull pain, a slightly excited circulation, and the other symptoms of constitutional participation. The inflammatory affections of the liver are always more slow in their course, and their termi- nations, unless by resolution, are more protracted. Hence suppuration, abscess, &c, are much longer deferred than in organs the structure of which renders them liable to real inflammation. Upon these principles we can understand, or at least plausibly account for, the utility of mercury in the early periods even of what are named inflam- matory affections of the liver. They are all mostly of the congestive or veno-congestive character, and mercury seems to exert a specific exciting influ- ence upon those parts of the vascular system which are more especially the seat of such con- gestions. The structure of the liver is found to consist of two substances: one apparently formed by the ramifications of its capillary vessels, presenting s reddish appearance; the other a yellowish white, and which is supposed to be chiefly concerned in the secretion of the bile. Although these two substances are in the natural state distinct, ye» some care is necessary to prevent their being con- founded. In engorgement, however, they are not to be distinguished, and, consequently, a uniform redness—purply redness—pervades the entire viscus. The blood sometimes escapes from the vessels, and is effused into the parenchyma, producing* species of bloody infiltration, named by the French writers hepatic apoplexy. Sometimes it arises from the rupture of a single, but large vessel, die- LIVER, (DISEASES OF THE) 145 tributed in the liver. In other instances, there is no perceptible rupture of any of the vessels; but spots are perceived dispersed in various parts throughout the organ. These spots, on being examined, are found to consist of blood, either in the fluid state or coagulated. Andral relates an instance in which, besides various collections of fluid and semi-coagulated blood, there were found some spots of a firmer consistence, in the centre of which were several fragments of hardened fibrine, deprived of the colouring matter. The examination of this condition induced him to investigate the question, whether fibrine thus deprived of its colouring matter might not be the origin of certain accidental productions, encepha- loid and others, frequently found in the liver; a conjecture in which he was confirmed by the exa- mination of another liver, in which he was able to trace the different changes of the blood, from its perfectly fluid state till it passed into a sub- stance resembling precisely the encephaloid in all its characters. (Vol. ii. p. 589.) Cruveilhier states that the first degree of hepatic phlebitis is often a circumscribed infiltration of blood into the tissue of the liver. (Dictionnaire de Medecine et de Chirurgie, t. viii. p. 326.) Anaemia is a condition directly the reverse of the foregoing, in which the viscus does not receive its due proportion of blood. This, however, more frequently arises from some morbid condition of the organ diminishing or obliterating the calibre of its vessels, as induration and various other organic changes. If, for instance, the white sub- stance of the liver be preternaturally developed, the red remaining either in its natural condition, or becoming altered in its colour, while its bulk diminishes as the red part wastes, it becomes less vascular; condensation takes place; it is converted into a species of cellulo-fibrous tissue, and the vessels are obliterated. 2. Derangements of the nutritive functions.— The process of nutrition and growth is subject to morbid derangements in the liver as well as in other organs; and in fact there are, perhaps, but few parts of the animal body in which such derangements are so frequent. They are not only very various in their nature, but give rise to various and frequently very opposite results. Hypertrophy of the Liver is a condition in which its volume is increased. This condition may be confounded with simple hyperemia, in which the bulk is also increased; but they are affections of a very diflerent character, the one being a preternatural accumulation of blood in the vessels; in the other the increase of volume depending upon the preternatural development of substance. The hypertrophy may be general, that is, the entire structure hypertrophied; or it may be par- tial, confined to particular portions of the struc- ture. The organ, also, may present various appearances as regards colour, consistence, and form. It may be pale, or red, or of various other tints, as green, grey, or brown ; this last in parts degenerating into complete black. The consist- ence may be either increased or diminished; it may be firmer and harder,—having a denser and more solid feel,—or it may be softer, and more approaching to flabby. If the hypertrophy be Vol. III. — 19 > equally and uniformly diffused, the change of form will be simply enlargement. But in some in- stances the hypertrophy is partial, and one con- stituent may be hypertrophied, while the other remains in the natural state, or even runs into, atrophy. This may give the liver " a lobulated, mamillated, or granular appearance." (Andral.) Hypertrophy may also be considered in refer- ence to extent. Thus it may occupy the whole of the liver, or only one or more of its lobes. When one lobe only is hypertrophied, it appears to constitute the entire of the organ, the remaining parts appearing more like appendages. When the right lobe is extensively hypertrophied, the left seems quite diminished, or to have nearly vanished. In the case of hypertrophy of the left lobe, the right seems to have diminished in size. The hypertrophy of the right lobe is sometimes such as to cause it to project considerably below the ribs, and in children sometimes to extend nearly to the ileum, occupying the whole lumbar region, and a great portion of the epigastrium. When the hypertrophy exists in the left lobe, it will often extend into the left hypochondrium, and not only may be, but has been, mistaken for an enlarged spleen. More frequently, however, it occupies the epigastrium, and the practitioner should be aware of this fact, because such projections, by careless or hasty observers, may be mistaken for gastric tumours, or for diseases of the transverse colon. The lobulus Spigelii, it has been asserted, is found frequently enlarged. More modern observa- tion, however, has not confirmed the assertion. It certainly is sometimes enlarged, but it does not appear that it is often found in a state of isolated enlargement. According to Cruveilhier, a considerable de- velopment may arise from accidental productions found in the substance of the organ. But this is not hypertrophy properly so called. It is not un- common, however, to observe such tumours ac- companied with a true hypertrophy of the tissue of the liver itself; so that there is at the same time with adventitious tissues an augmentation of the proper substance of the organ. In other cases the liver is the seat of an extravasation, from which results a pure and simple augmenta- tion of volume without any alteration in its sub- stance. (Diet. &c. p. 326.) In the foetus, and for some time after birth, the liver maintains a volume very disproportionate to that which it subsequently preserves. As age advances, the size of the liver comparatively di- minishes, and it appears much reduced; it is consequently retracted, or rather drawn upwards, and its edge can be no longer felt projecting below the margin of the ribs. This is the natural con- dition ; but in some cases this natural reduction in volume is so far from occurring, that the growth increases, and the liver becomes still more dispro- portionately enlarged. Thus the hypertrophy may continue progressively after birth, or it may cease for a while; and the liver, after having re- tired nearly within its boundaries, will suddenly, and without any manifest cause, continue to in- crease, until it arrives at an incredible and most distressing size. This state of the liver is very often merely one of that combination of perver- LIVER, (DISEASES OF THE) sions in the nutritive functions which together constitute the scrofulous diathesis. Atrophy is the directly opposite condition of that just considered. Atrophy, though generally accompanied with reduction in volume, yet is not necessarily so. It may extend to all the lobes, or affect only one. Like the preceding condition, it may also be attended with induration or soft- ening. Though generally attended with a diminution of size, yet an augmentation of volume is by no means incompatible with an atrophied condition. Sometimes the size of the organ, though atrophied, exceeds the natural, and the atrophy consists in the removal of the proper tissue, cellular tissue being substituted in its stead. In these cases there is a defect in the organization, and the structure, as it were, reduced to its primitive frame-work, presents extensive patches of cellular tissue. This tissue is sometimes formed into serous, or contains hydatids, or it may become hypertrophied ; which, it is argued, so far from implying an increase of organic action, rather in- dicates a deficiency ; the tissue being unequal to the production of the true parenchyma, degene- rates into a serous cyst. The atrophy may be partial, and then the glandular grains which have not been atrophied become enormously developed, to supply, as it were, the deficiency caused by those which have been removed. Cruveilhier states that he has sought in vain in the vessels of the liver, whether arterial or venous, for the cause of the atrophy of the organ. They are diminished in a ratio directly proportioned to that of the liver, but nothing tends to show that this diminution has been a primary operation. (Loc. cit.) Atrophy of the liver is observed in a great variety of circumstances. In some cases of re- tention of bile in consequence of the extreme distension of the hepatic ducts, the liver has been reduced to half its natural size. In indurations, too, it has appeared atrophied, so that its glandular structure was hardly to be recognised. The partial atrophy seems in general to arise from pressure upon the liver, either by tumours found in the immediate neighbourhood of the organ, or from those formed in the substance of the viscus itself. Induration.—This state may exist simply, or combined with hypertrophy or atrophy. The colour varies, being either a purple or lighter red, or grey olive or brown. On cutting into a liver in this condition we observe no peculiarity of structure, but it appears rather a confused and un- defined mass. The surface of such livers not unfrequently presents the appearance of mem- branous threads, of a radiated figure, the lower edge bent a little forwards. Baillie considered this the first step in the formation of the common tubercular liver. He observes, " I have some- times seen very small tubercles formed upon a part of the surface of such a liver, which were exactly of the common sort. From this appear- ance it is probable that additional matter is depo- sited in the interstices, through the general mass of the liver, rendering it much harder, and that this matter, together perhaps with part of the ordinary structure of the liver, is converted into tubercles." (Morbid Anatomy, c. ix. Diseasej Appearances of the Liver.) Cruveilhier has often found indurated livers of a green olive colour, of great density, tearing et giving way with extreme difficulty, and of a vo- lume less than in the natural state. The glands appear atrophied, and the fibrous envelope of each granulation thickened. In place of bile, the biliary vessels contained a kind of serosity tinged of a bright yellow. In a patient who died, aftsn a tedious green jaundice, in a manner similar to those who died of cancer in the liver, the only alteration discoverable on dissection was that above described. By far the greater proportion of indu- rations of the liver are accompanied with a dimi- nution of its volume. Softening.—This condition is said to be ■ common as the foregoing, which, however, does not accord with the writer's experience, at least among the troops; still it must be allowed thet softening is a very frequent morbid condition, There seem to be two degrees of it: in the one the softened consistence is not perceptible unless it be compressed between the fingers; k then readily gives way, becoming a kind of pultaceous mass. In some cases the liver is so softened that it is impossible to detach it without tearing it into shreds ; and when the peritoneal covering and proper investing membrane are broken, they re- duce to a sort of brownish yellow pulp. This alteration has been looked upon as cadaveric, s view, however, which appears to be unfounded, The liver itself appears a kind of pulp deprived of every semblance of organization. It has no fetid odour. When put into water, an immense number of small yellowish granules appear. These are quite distinct, seem as if dissected, and .resemble the small seeds which present in dried grapes or raisins, attached to the large vessels by vascular pedicles. In the other the softening ap- pears evident to the eye, and somewhat resembling that acquired during long-continued maceration. The vessels, or at least the extreme branches, seem to float in a reddish or greyish-looking pulpy mass, and which seems to be nothing more than the dissolved parenchyma. The colour is in some instances natural; if| however, there be hyperemia, the colour will be purple or brown, but it frequently happens that in consequence of some modification of structure, the colouring matter of the blood cannot pen* trate the tissue, and it appears remarkably pale. In such cases the only traces of blood are confined to the large vessels. Baillie, under the head of softened substance of the liver, states that it is found much more flaccid than natural, without any other appear- ance of disease. It feels as soft as the spleen to the touch, and is then mostly of a leaden (q.*- purple) colour. This change he considers roost arise from a process similar to what Hunter named "interstitial absorption," the absorbents removing insensibly the very minute parts of structure without ulceration. This state he looks upon as mostly confined to advanced age, beioj rarely, if ever, found in very young persons. Tubercle of the Liver. — Baillie notieei several forms of tubercle in the liver; such « LIVER, (DISE. i — common tubercle of the liver, large white tubercle ; of the liver, soft brown tubercle, and scrofulous 't tubercles. : Common tubercle is confined to persons of ";. middle or advanced age, being very seldom met ' with in young persons. It is likewise more com- mon in men than in women, and more apt to » occur in persons addicted to spirituous liquors. Baillie describes such tubercles as near each other, of a rounded form, and giving an appearance of irregularity to the surface. They consist of a brownish or yellowish white solid matter. They vary in size from that of a pin's head to that of , a hazel-nut, some of them even exceeding this. The liver is in such cases indurated, and its lower ;, edge bent a little forward. The liver itself is of „ the healthy size, or sometimes smaller, and on , section of the substance the patulous vessels seem , reduced in their calibre. The colour of the liver is yellow, which is attributed by Baillie to the accumulation of bile in its substance; and as this condition is almost uniformly accompanied with ascites, the fluid accumulated in the peritoneum (- is almost always tinged yellow, from mixture with bile. The gall-bladder is described as being much contracted and white, from being empty. The bile, it is asserted by the same authority, "_' from the pressure of the hard liver upon the pori biliarii, does not reach the ductus hepaticus, and L consequently cannot pass into the gall-bladder. Permanent jaundice is also established, because it ' depends upon an unchangeable morbid condition - of liver. When the jaundice has continued for a considerable time, the blood in all the blood- vessels of the body is found either not coagulated at all, or very imperfectly so; and this is attri- " buted to the chemical influence of a mixture of - bile with the blood. This is the appearance of what is named "scirrhous liver;" but it bears •' only a remote similarity to scirrhus as it appears in other parts of the body. (Morbid Anatomy, • c. ix.) ? Large white tubercle of the liver.—Under this name Dr. Baillie describes hard white masses ■: sometimes formed in the liver, varying in size, i being in some cases considerably larger than a chcsnut, and in others a good deal less. They t are more numerous near the surface than in the r. middle of the substance. They are in clusters, t with the healthy structure interposed; are of a firm consistence, and constituted of an opaque t whitish substance ; they are hollow, or depressed 5 upon their outer surface; and the liver is gene- ,. rally enlarged. This form seems to be generated round the . blood-vessels, as appears from making sections. It may or may not be attended with ascites. Sometimes bile is accumulated, tinging the sub- stance of the liver, the colour remaining natural , between the tubercular masses. Dr. Baillie as- serts that he has observed a sort of pus lodged in these tubercles very much resembling that from scrofulous sores; and he therefore concludes that this species may be of a scrofulous nature. Soft brown tubercle.—These generally consist of a soft, smooth, brownish matter; are about the size of a walnut, and mostly occupy the surface ' of the liver. They are a rare form. Scrofulous tubercles. Tubercles resembling \SES OF THE) 147 j those found in the lungs of scrofulous or phthisi- cal patients, are said to be occasionally found in the liver. They are said to resemble them pre- cisely, except in being a little browner in colour. They are dispersed and solitary, and do not give that irregularity of appearance attendant on the other forms. The liver in children is frequently found in a tuberculated state. The tubercles are about the size of a millet-seed, hard and semi-transparent, so as to be sensible to touch as well as sight from their density, but yet would escape a careless ob- server. Such are the forms and varieties of tubercle enumerated by Baillie ; but there is reason to be- lieve that the nature of these appearances was not thoroughly understood in the days of that highly distinguished anatomist. It has been already observed that the structure of the liver consists of two distinct substances; the one a reddish purple, formed by the capillary ramifications; the other of a whitish or yellowish colour, and which seems to be the part which se- cretes the bile. In the natural state these two substances are distinct, but an excess of blood destroys all distinction. On the other hand, a de- ficiency of blood renders the yellow substance more distinct and evident; and the privation may be such that the reddish substance may be de- prived altogether of colour, and the liver assume a whitish tinge throughout its entire substance. This appearance may be very much modified as changes predominate in the texture of the parts forming the hepatic mass. The yellowish sub- stance may become hypertrophied, and this admits of various degrees. In one kind the substance is marked by the transit of whitish lines; in the other it is granulated ; and these granulations, whether isolated or agglomerated, assume the ap- pearance of yellow wax. These granulations Laennee considered as an accidental (adventitious) tissue generated in the liver, and named it, from its colour and appearance, " cirrhosis." He also asserts that what he terms cirrhosis is accompa- nied by a shrivelled state of the organ; and it is almost always accompanied by ascites. (See Baillie on the common tubercle of the liver.) Cruveilhier, who has given an excellent plate of this condition, (Anatomie Pathologique du Corps Humain, 12elivraison, planchelre,) has examined and described its minute anatomy very attentively and accurately. He found the liver reduced to about a third of its ordinary weight and volume: the right and left lobes nearly equal in size, but remarkably altered. This double character, dimi- nution in volume and change, is a very constant occurrence in these affections. The tissue is also denser than is natural. The surface of the liver is not smooth but roughened by a number of granulations (tuber- cles), between which there are depressions, wrinkles, and thickenings, and the organ might be said to be dried up, as it were, withered, its in- vesting membranes irregularly thickened, and opaque in many parts. Cartilaginous lamina? were found upon the inferior surface of the left lobe, and which were part of the peritoneum. The colour is yellow, varying from a bright or canary to a brown yellow, depending upon the 148 fluid with which the tubercles are penetrated. These tubercles, if squeezed upon white paper, tinge it yellow. The quantity of colouring mat- ter, though various in the different tubercles, seemed in direct proportion to their size. The blood-vessels traversing the tissue were found healthy, but the blood which they contained was serous (watery); the biliary-ducts and the gall- bladder full of a yellow bile, more or less inspis- sated. On removing the investing membrane, which was done in several places, the tubercles were found to differ in size; and some, of the size of large peas, had a number of others beside them of the size of millet-seeds; and this gave the irregu- larity of surface to the liver. Each tubercle was found to be perfectly distinct and unconnected with the neighbouring ones, was provided with its own proper membrane, and was connected with the liver only by a mere vascular pedicle. On a section of the liver these observations were confirmed ; that is, the separate existence of the tubercles and their colour. But farther, it demonstrated that there existed, independently of the tubercles, a very dense fibro-cellular tissue, altogether foreign to the natural state. A section of one of these tubercles, examined by the micro- scope, presented precisely the same characters as the section of a healthy liver, namely, a spongy tissue analogous to the pith of a rush. On examining into the characters of these tu- bercles, they seem to be nothing more than an un- natural development of one structure at the ex- pense of the other—" une dissociation des deux efemens naturels de cet organe: Ies masses jaunes, fauves, constituant le tissu accidentel appele cyr- rhose, ne sont autre que Ies granulations secre- toires, se desorganisant graduellemen par Peffet de 1'obliteration du lacis vasculaire, et Pobstacle a la circulation hepatique qui en resulte." (Memoire par M. Bouillaud insere parmi ceux de la Societe Medicale d'Emulation, torn. ix. p. 170.) The ex- amination also proved that nothing more is neces- sary to give a tuberculated appearance to the liver than an unusual development of the acini, and hence it is unnecessary to suppose the production of a new tissue to account for the phenomenon. [M. Cruveilhier, however, does not admit that the granules are formed of two distinct substances. His views of cirrhosis are, that it consists essen- tially in atrophy of the greater number of granu- lations, and hypertrophy of the remainder to sup- ply the deficiency thus engendered. The two dis- tinct substances in the liver—the yellow, the se- creting tissue, and the red formed by ramifica- tions of blood-vessels—are, however, by no means generally admitted, and until their existence is es- tablished, any theory founded upon them cannot be implicitly received. The views of Mr. Kiernan in regard to the minute anatomy of the liver (Philosophical Transactions, for 1833, p. 711, or the writer's Human Physiology, 5th edit. ii. 268, Philad. 1844) have given rise to another explana- tion which is considered by Dr. Carpenter (Prin- ciples of Human Physiology, § 659. Amer. edit. Philad. 1843) to be satisfactory. The small masses are regarded as uncongested patches, composed of parts of several adjoining lobules, and having one or more interlobular spaces as a centre; and the LIVER, (DISEASES OF THE) biliary plexus of these, being filled with bile, ghn them"their yellow colour. In the other, there i,, more or less complete atrophy of the portion, of fc substance of the liver intervening between then so that the size of the liver is much diminished This may be the true explanation; but, as else- where remarked, (Practice of Medicine, 2d edit i. 600, Philad. 1844,) the opinion of Laennechsi appeared to the author to be most entitled to f*. vour ; and the circumstance, that, in certain forms of cirrhosis, little granules, having the appearance of adipocire, can be washed out of their cellulir fibrous capsules, after a maceration of some days in water, is greatly in favour of their adventitious formation. The matter, of which the rounded masses in cirrhosis consists, is not considered by Mr. Goodsir (Lond. and Edinb. Monthly Jour.of Med. Science, May, 1842) as a new deposit, but merely as the natural tissue of the liver, altered by the pressure exerted by its fibrous envelope. These alterations consist in constriction, more ot less powerful, of the vessels and ducts which pass out of and into the rounded mass; the necessary difficulty with which the circulation is carried on, and the bile advanced along the ducts; and, lat- j terly, in a change in the constitution of the nn- ■ ■_■. cleated cells themselves, which, instead of being . distended with bile containing oil-like globules, jr contains matter of a darker colour than oil. The „- cells may at last contain matter perfectly black, L and then the rounded mass assumes the appear-1.-,: ance of a melanotic tubercle,—the black cells, in ■■,, some instances, being pyriform and caudate. Mr. ■ Goodsir does not state the exact nature of these : various changes in the liver, although he is in- clined to believe that the forms of cirrhosis and r; melanosis are due to the contractile tissue, as s<(f product of inflammatory action more or less acute. ; His remarks on the whole subject can only be:,.! regarded, however, in the light of suggestions.] ,i-. Tubercles in the livers of adults are very rare, and Cruveilhier asserts that he never met with i them in the numerous cases of pulmonary and - abdominal phthisis which he has had occasion to; examine.* He states that he has seen the liver of an individual full of tubercles, each formed by a dense cyst containing a drop of pus; at the same time there were a great number of calcuUio the biliary passages. The small multilocular« unilocular cysts formed by the roots of the ex- cretory biliary ducts are often confounded with and mistaken for tubercles, when containing small calculi, or a liquid tinged with the bile. Cruveil- hier has very often met with this kind of altera- tion in both the* livers of newly-born children end in adults.-j- Krectilc Tumours of the Uver.—Cruveil- hier describes an affection of the liver in which the tumours resemble the tissue of the corpus «• vernosum penis. They are very common not onlj in the liver but in other organs. Sometimes the; are solitary, sometimes numerous. They appea' to be formed of a greater or less mass of granu- lations, and are capable of an indefinite incree* * "Les tubercules du foie sont tres rare chcz I'adeHS! je ne les ai jamais rencontre dans les cas noinl»reuH» plithisie pulmonaire, de plithisie abdominale, que j'ai*« occasion d'exaininer." Dictionnaire de Medecineet* Chirurgie, torn. viii. p. 32a. t Ibid. p. 330. LIVER, (DISEASES OF THE) 149 In one instance, in the centre of the tumour there ! was a mass of fibrous tissue, from which prolonga- | tions extended, which in their growth passed in all directions. In another instance a carcinoma- I tous tumour accompanied the erectile. (Diction- nairc de Mcdecine, &c. p. 330.) Flaccid Liver with Reddish Tumours is a state noticed by Baillie, in which the liver is un- usually flaccid, and studded with large reddish soft tumours, containing a thick pus. They were found in a person presenting the leading charac- ters of the scrofulous diathesis. He considers them in some measure analogous to fungus haema- todes. Fatty Liver.—This is a condition more com- mon in the lower animals than in man. While a fatty or adipose state of the other organs and the muscles in particular seems to be the last stage of atrophy in them, the same appears to be the last stage of hypertrophy in the liver. The fatty liver in the human subject never assumes that complete adipose transformation induced in the livers of geese, ducks, &c. by the agency of the most ab- solute rest or inactivity, darkness, and the artifi- cial ingestion of an immense quantity of ali- mentary matter. The liver, however, in the hu- man subject undergoes, to a limited extent, a true fatty transformation. The discoloured liver ob- served in cases of phthisis is frequently confounded with the true Tatty transformation ; but chemical analysis disproves this opinion, by showing that the fatty material does not exceed the proportion naturally belonging to the normal condition of the organ. [Recently, Mr. Bowman has suggested, and Mr. Goodsir accords with him, that the fat in adiposis of the liver is deposited within the nucleated cells of the organ, and that the disease is to be con- sidered, in part, as a redundancy of the oil-globules naturally existing in these cells, with atrophy of * the other structures.] Phlebitis of the Liver. — This affection is frequently a consequence of inflammation of some of the other veins. It frequently follows large wounds or surgical operations, and is thus not un- frequently an antecedent to traumatic abscess. Cruveilheir asserts that he has often induced it by the injection of irritating agents, into either the general venous system or into the vena portae. (Dictionnaire de Medecine, p. 327.) The circum- scribed inflammations of the liver consequent upon phlebitis present every degree from the red induration to the actual formation and collection of pus. It has also been caused by inflammation of the haemorrhoidal veins. Thus Cruveilhier re- lates an instance in which long-continued, violent, but ineffectual efforts to reduce an old prolapsus ani produced so much irritation of the rectum, that inflammation of the haemorrhoidal veins suc- ceeded, which extended to the veins of the liver, and terminated in a number of abscesses, both superficial and deep-seated, in this organ. The phlebitis may be confined wholly to the capillary system, as it may at the same time occupy both the large veins and the capillaries. Cysts are often observed in the liver, of which the causes are various. Hydatids are very often seen in the liver, and are mostly contained in a cyst. The cyst is j formed of dense, firm, unyielding material, some- thing like leather or fibro-cartilage. It is generally laminated. The laminae are composed of white matter ; and the cavity is sometimes divided by a partition formed of the pulpy substance lining the laminae. (Baillie.) The cyst may'contain a sin- gle hydatid, or they may be numerous. The hydatids are found loose in the cavity, and floating in a clear transparent fluid. They appear like small, rounded, sometimes oval-looking bags, which are said to consist of a white semi-opaque pulpy matter, containing a fluid capable of coagu- lation. (Ibid.) In an examination of a liver con- taining a cyst full of hydatids, which occupied more than three-fourths of its volume, leaving but a small portion of the right and left lobe free, the writer found the hydatids perfectly transparent and pellucid. In this case the liver wa3 reduced in size, and the emaciation and contraction of the intestines were such that the bodies of the vertebrae could be distinctly felt through the abdomen, and counted. It might be almost truly said the perito- neum lining the interior muscles of the abdomen rested upon the bodies of the vertebrae. In some cases the colour is of a lightish amber. The bag in which the hydatid is contained seems to consist of two laminae, and to. possess a con- tractile power. The larger hydatids are occasion- ally found to have smaller ones attached to them. In some cases the hydatids are connected, and even found to enclose each other like a set of pill- boxes ; in other instances they are distinct and unconnected. Hydatids are generally found occupying the substance of the liver, but occasionally they are attached merely to the outer surface, hanging pen- dulous into the cavity of the abdomen. Cruveilhier (Planche v. troisieme livraison,) describes a curious instance of ascites, anasarca, and icterus with " deux kystes acephalocystes du foie." The patient, a man of thirty-eight years of age, and vigorous constitution, had been wounded, in 1814, in the epigastrium by a musket-shot. About the year 1828 he was troubled with vomit- ings, and with pains in the stomach, every fifteen days, and which had commenced about a year after his accident. He was bled, and leeches were applied, with other treatment. Scarifica- tions were made on the extremities, subcutaneous inflammation followed, and he died comatose. On opening the abdomen, instead of perito- nitis, as was anticipated, nothing but a citron- colour fluid appeared. The liver presented a singular appearance. The antero-posterior diam- eter equalled the transverse and the vertical very nearly the same at the right as at the left extre- mity. The left lobe was atrophied, and the sur- face of the liver shrivelled, and roughened by granulations of unequal volume and differing in form. There were two lari>e fluctuating tumours, one on the right and the other on the left. Supe- riorly they did not extend beyond the level of the organ; but inferioily the left formed a kind of spheroidal bulging of considerable size. Both tumours presented superiorly a very bulging sort of appendix traversed by sanguineous vessels with very thin walls, and which would have soon burst into the peritoneal cavity. The cysts on being opened were found filled with a muddy yel- 150 lowish fluid, in the midst of which were both en- tire and empty acephalocysts connected together and coloured yellow. On examining one in its perfect state there appeared some white points, like small grains of sand, more resisting than the other points, vulgarly but erroneously regarded as the germs or eggs of acephalocysts. The figures or shapes were very singular and varied, and which it is asserted the partisans of the vitality of these organized globules will refer to defects in the conformation arising from a straitened de- velopment. On examining the primary mem- brane lining the left cyst there were agglomerated tubercles roughening the internal surface, which might be compared to small e%?s. In a portion from the right there were vesicles in clusters, some regular, some irregular, and which Cruveil- hier thinks we should feel some difficulty in re- garding as the germs of acephalocysts ready to detach themselves. The enveloping cyst was fibrous and a quarter of a line in thickness. The internal surface ru- gous, as it were torn, and studded with concre- tions, in some places brown, in some green, in others yellow, and in some a most beautiful orange yellow ; all which shades arise from the colouring matter of the bile some way modified. These concretions, wbifch Cruveilhier asserts he has seen several times forming a thick lining or bed similar to biliary calculi, lining the entire of the cysts, prove evidently, he says, the communication, a temporary one at least, of the cyst with the biliary tubes or canals. The cyst was easily detached ; and a loose cel- lular filamentous tissue connected it with the liver, to the substance of which it was attached merely by a number of arte'rial and venous vessels and hepatic tubes, of which a great proportion was obliterated. The cyst of the left lobe, which extended below the level of the liver, compressed the left division of the vena portae, which was narrowed in an extraordinary degree, to which circumstance the atrophy of the left lobe in this case is attributed. The corresponding branch was on the contrary dilated. On examining a portion of the liver by making incisions, it was found tuberculated, the tubercles separated by interspaces of different extent. In the interspaces the liver had a fibrous aspect, and did not present, in a given proportion, above half the glandular structure belonging to the na- tural state. The subcutaneous phlegmonous inflammation with infiltrated pus, occupying the lower extremi- ties and extending to the thighs, is considered by Cruveilhier to have been occasioned by the scari- fication of the anasarcous extremities, and to have been the cause of the succeeding coma, and ulti- mately of death. Cysts containing an Earthy Matter have been found in the liver. They are generally formed of a kind of fibro-cartilaginous, dense, firm membrane. Sometimes it is partially ossified. The earthy matter is gritty, sometimes plastic, and of a whitish colour. It consists chiefly of phos- phate of lime, and very probably is merely the commencement of osseous deposits in the sub- stance of the liver. LIVER, (DISEASES OF THE) ""cysts containing Worms have been said to be found in the liver and likewise in the biliary ducts. Lieutaud relates instances of this sort, but they are very rare, and the fact seems even rather doubtful. Rupture of the Liver is an injury to which it is exposed from external violence, and is an ac- dent to which it is more liable than any other This greater liability Dr, gland in the body. Baillie attributes to two causes ; first, its more exposed or rather less protected situation in thin persons, if the liver be enlarged ; secondly, be- cause its structure is such that it yields to external violence more readily than any of the others. The accidents from which such ruptures occur are heavy weights falling upon the abdomen or pass- ing over it. The writer saw an instance of this sort at Chelmsford some years ago. A carter fell from his wagon, which was heavily laden, and the wheels passed over him in the region of the liver. He lived a very little time, but did not complain of much pain, except from the bruise, On opening the abdomen the cavity of the perito- neum contained an immense quantity of blood, the liver and spleen were ruptured, as was also the vena cava, from whence the haemorrhage took place. Traumatic Abscess of the Liver. — Ab- scesses after wounds, &c. are apt to form in dit ferent organs, but in none more frequently, after the lungs, than in the liver. These abscesses varj both in number and extent. Sometimes there exists but one, sometimes there are two or three small clusters. In some cases there is but a single abscess; and in an instance mentioned by Cru- veilhier, of death in consequence of gangrenous inflammation of the pelvic cellular tissue, induced by infiltration of urine, on examination there was found but a single abscess in the liver, and seated in the loose cellular tissue which surrounded one of the divisions of the vena portae. In other cases the liver presents an immense number of small spots or foci of a tubercular appearance. On tracing these abscesses through their pro- gress from their first formation, they appear at first as brownish bloody spots, which seem to be situ- ated in the glandules themselves. 2. Infiltration of white concrete pus, which gives an appearance of granite to the liver, with a slate brown colour all round, without any other evident trace of in- flammation. Sometimes a great number of the glandules are affected; in other cases it is limited to a very few, which with the density of the pus, the number of foci or clusters, and the irregularity of the massps affected, has given rise to the ides of their tubercular nature. The surface of the liver next the cluster always appears of a slate- brown colour, which is probably cadaveric. 3. A collection of pus of abscess, the dimensions of which exactly equal those of the masses first af- fected. The causes of such abscesses are wounds of different kinds, surgical operations, and phlebitis They seem to arise from the transmission of pu» with the blood through the veins ; a fact which accounts for the much greater liability of the lungs and liver to these kinds of abscess. The diagnosis is extremely difficult; sometimes there is pain in the right hypochondrium and right shoulder. In LIVER, (DISE other cases the region of the liver may be pressed upon it in every way without the slightest indica- tion of sensibility. Jaundice is very uncertain. If, however, several days after a wound or sur- gical operation a patient should be seized with shivering, and suddenly sink into the extreme of a typhoid state, with no manifestation of disease in any of the other organs, a suspicion of the ex- istence of this result may be entertained. Abscesses sometimes, it is said, form in the liver in consequence of injuries done to the brain. This form is said to arise from irritation. The subject, though considered at some length by Cru- veilhier and some other writers, requires further researches. Melanosis. — The liver is liable to become melanotic During the progress of the disease the liver sometimes enlarges to such an extent as to occupy nearly the whole of the abdomen, and in a female might be mistaken for pregnancy. A case of this kind is related by M. Ruyer in the Encyclographie des Sciences Medicales. The patient, a woman about thirty-three years of age, had enjoyed very good health till the month of June, 1833, about which time she was ill-treated by her husband, and in a very violent manner. He kicked her upon the chest and abdomen in several places, and several contusions were the consequence, which were wholly neglected. After some days, dull pains were felt in the region of the stomach, extending to the lumbar spine. In the course of a few days the pains disappeared with- out any treatment, reappearing however at uncer- tain intervals, with various degrees of severity, according to the exercise to which she was forced to subject herself. The abdomen at this period was of its natural size. In January, 1834, she was confined of a healthy child, which she suckled for eleven months. After confinement the belly diminished very little in size, and felt equally hard. She perceived that the abdomen enlarged, and she felt all the symptoms of pregnancy : she became much emaciated, and at last died. The abdomen was extremely hard and enlarged, and on opening it about three pints of a serous-looking fluid escaped. The liver filled up completely the whole of the abdomen, pressed the diaphragm high up into the thorax, extended into the right iliac region, and terminated by a protuberance of a spherical form. The entire structure was altered from the normal condition presenting a confused mass. Extensive adhesions existed between the anterior part of the stomach, a considerable por- tion of the transverse colon, and this hepatic de- generation. It pressed the whole of the intestines and other viscera against the vertebral column. It weighed twenty-four pounds. It was softer, more friable, and more easy of incision than in the normal state. It was of a violet brown slate colour, and studded with a number of whitish tu- mours, varying in size from that of a millet-seed to that of a hen's egg. The abscesses contained a homogeneous liquid of a purulent consistence. The gall-bladder was much enlarged ; its contents almost black. The other abdominal viscera were natural. The vertical diameter of the thorax was reduced one-half; the heart of its usual volume, but displaced, its apex directed upwards; the lungs reduced in volume; their tissue soft, little , ASES OF THE) 151 crepitous, and easily torn; and there were nu- merous adhesions between them and the pleura costalis. Cancer of the Liver.—The term cancer, a» applied to diseased appearances in the liver, com- prehends certain morbid productions deposited in its parenchyma. They are of different kinds, produce masses of various sizes and extent. They are mostly white, the white being sometimes mixed with red. Cruveilhier observes—" Of all the diseases of the liver, the most frequent and the most severe is, perhaps, the cancerous degen- eration in the form of disseminated masses." They vary in extent, are somewhat spheroidal, and deposited in different parts of the substance of the liver, or near its surface in the midst of the per- fectly healthy tissue, the organ appearing, as it were, filled with them. There is mostly a perfect line of demarcation between the tissue of these tumours and that of the liver, and the transition is abrupt, not gradual. These tumours seldom appear solitary, that is, a single and only one, and in the few instances which Cruveilhier met with, upon close examina- tion there existed a number of small miliary tumours, which from their tenuity would readily escape hasty observation. They vary in number from eight or ten to several hundreds or more. These cancerous tumours are commonly con- fined to the surface. In a liver containing twenty tumours of this description, sixteen were found near the surface or superficial. (Cruveilhier.) The superficial ones are generally prominent, so that they can be felt through the abdominal pari- etes ; and they may often be recognised by touch after the operation for ascites, frequently necessary in the advanced periods of this disease. But when they become large or extensive, they lose their spherical shape and become hollowed out or cupped in the centre, in consequence, probably, of the thickening of the corresponding cellular tissue under the peritoneum. The peritoneum itself often becomes thickened, fibrous, and cartilaginous; and adhesions take place between the liver and contiguous parts. The situation in which the larger cancerous masses generally appear is the part which cor- responds to the suspensory ligament, and conse- quently the antero-posterior ridge. Hence, per- haps, the reason why adhesions occur so frequently between the liver and stomach, and why these cancers open in the latter. The lobulus Spigelii is frequently affected, even throughout its entire substance, so as to appear a prominent encepha- loid tumour. (Cruveilhier.) These tumours also vary in size, from that of millet-seed to a turkey's egg, or the two fists, or even the head of a full-grown foetus. From all the facts, their size, appearance, consistence, &c., it may be inferred that they are formed at differ- ent periods. There seem to be two varieties of them, which do not exclude each other; the hard or scirrhous, and the soft or encephaloid. These are generally considered but degrees of the same disease; but, according to Cruveilhier, this is in- correct, and the expressions, " period of crudity, period of softening," are improper. The hard kind appears with an areolar web, which grates under the scalpel, composed of ex- 152 tremely dense, fibrous, and sometimes even carti- laginous meshes. It may be said that the tissue is fibrous, or even cartilaginous. There are small cavities in the centres of the tumours, filled with a fluid, crossed by fibrous bands more or less re- gular. On the pressure a lactescent cancerous juice exudes. If macerated in water or a weak solution of chlorine, the cancerous matter is dis- solved, leaving a marginal fibrous tissue behind, somewhat analogous to the erectile. Sometimes the centres of the tumours are overrun by blood- vessels well developed ; in others the vessels are so reduced in calibre, that it requires some atten- tion to discover them. The soft kind is of a greyish white colour, resembling the infant brain. It is the encephaloide cancer of Bayle and Laen- nec. In some cases it is very white when not much overrun with blood-vessels, but where the vessels are numerous the quantity of blood gives it the character of apoplectic spots. Ossification.—Bony depositions are some- times found in the liver. The writer once met with a piece of bone imbedded in the substance, about the size and somewhat of the shape of the human patella. It resembled common bone, con- sisting almost entirely of phosphoric acid and lime, with a very small proportion of the carbonate of this earth. The upper surface rose very little above the level of the liver, and its entire depth or thickness was imbedded in the parenchyma. Diseases of the appendages may be divided into those of the ducts and those of the gall- bladder. Dilatation of the biliary ducts.—The cystic, the hepatic, and the ductus communis choledochus are liable to dilatation ; mostly effected by large gall-stones making their passage through tne duct, which sometimes is so far dilated as to measure an inch in diameter. (Baillie.) Obliteration is frequently produced by in- flammation, especially of the inner surface, termi- nating in adhesion. Hyperaemia of the mucous lining may cause such a swelling as will totally obstruct the passage of the duct, and this obstruc- tion, however induced, may give rise to jaundice. Long-continued irritation may induce hypertrophy of the sides of the ducts, and produce an oblitera- tion, the duct itself being transformed into a fibrous cord. Thickening and hardening of the duodenum or pancreas may, by compressing the ducts, obliterate them. The gall-bladder is likewise subject to cer- tain alterations; such are adhesions, ulcerations, thickening, and ossification. Gall-stones are frequently found in the biliary ducts and in the gall-bladder. Sometimes the gall-bladder is completely filled with them, and then it is usually much enlarged. The number varies, but it is occasionally very great :* some- times but one is found ; it is generally very large ; when numerous, they acquire different shapes from friction. The writer was furnished with two passed by a lady, which were flattened somewhat like a bean ; the area about half as large again as a shilling, and much thicker than a bean. They were brown, smooth, and polishe.l outside; sawn through they presented a bluish slute-coloured ap- * In Dr. Hunter's collection was an instance of above a thousand in one gall-bladder. LIVER, (DISEASES OF THE) pearance; fracture rather striated ; they consisted of phosphate of lime, trace of carbonate, and some animal matter. There was very little cholesterine in proportion to the other components. They were extremely hard.f These biliary concretions occupy all parts of the liver, the biliary ducts as well as the gall-bladder, and the larger ducts for the transmission of the bile. They produce fre- quently great irritation, inflammation of the mu- cous tissue, ultimately terminating in ulceration, In some cases the dilatation of the gall-ducts will allow them to pass into the intestines, and they are then voided by stool. Cruveilhier has given two very excellent plates illustrating the diflerent situations and effects of these concretions upon the tissues. Bile.—The bile, as might a priori be inferred, is liable to morbid changes, and it possibly might be presumed that the extent of these changes would in some degree correspond with the altera- tions in structure of the secretory organ. This, however, is far from being the case; and observa- tion has been unable to establish any uniform connection between the alterations in the liver and the qualities of the bile. In many cases of severe organic disease of the liver, the bile appears to undergo little change; and the most obvious changes in the bile, and the most considerable augmentation in quantity, are sometimes accom- panied by no recognisable change in the normal condition of the secreting organ. It is true we very often estimate the quantity secreted by a very uncertain scale, namely, the quantity discharged from the intestinal canal or the stomach in bilious diarrhoea and in cholera. Neither the quantity nor quality of the fluids secreted from the blood depend absolutely and essentially upon the nor- mal conditions of the organic structure of the or- gans ; and the experiments of Magendie have shown that the composition of the bile, and even its quantity, may be altered and increased at plea- sure by changing the food of the animal. Cholesterine.—Chevreul detected in human biliary calculi a peculiar crystalline matter, which he named cholesterine. Fourcroy considered it analogous to adipocire, and so named it; but Chevreul has shown that it is an independent principle. It is a brittle, lamellated, brilliant crystalline solid, somewhat like spermaceti in ap- pearance, from which it differs by being infusible under 278° Fah., and in not being converted into soap by a solution of potass. It is devoid of taste and smell, and is insoluble in water. It dissolves in boiling alcohol, but is deposited on cooling in white pearly scales. According to Chevreul, its analysis yields— Carbon....................... 85.095 Hydrogen-----............... 11.880 Oxygen...................... 3.025 100.000 Nitric acid converts it into an acid, which has been named cholesteric acid, insoluble in water, but perfectly soluble in alcohol, especially if heated. Taste styptic, odour that of butter; lighter than water, and fusible at 136A0 Fah. In quantity it is of an orange yellow tint, but eva- t As these calculi were voided~Dy siool their origin may seem somewhat doubtful. ' S LIVER, (DISEASES OF THE) 153 porated spontaneously it is deposited from its so- lution in alcohol in white acicular crystals. It reddens litmus paper, and neutralizes the alkaline bases, and hence is an acid. Cholesterine has been found in parts of the body wholly unconnected with the hepatic circu- lation, and from these facts it would seem to be a product of morbid vascular action under peculiar circumstances. Breschet found it in cancer of the intestines, and in the fluid of hydrocele and of ascites. Caventou found it in an abscess of the jaw, produced by a carious tooth. Christison found it in an osseous cyst of the kidneys, and in the membranes of the brain in epilepsy. The bile of the human subject is liable to be- come diseased. In some cases, if tasted, it pro- duces no other inconvenience than bitterness and a nauseous sensation; but in others, it will pro- duce pustular affections, ulcers, and all the acridity which belongs to the most powerful agents of this class upon the tongue and lips. This must be owing to the bile having acquired some acrimoni- ous properties, derived, no doubt, from certain morbid changes in its chemical constitution. The sensible changes exist in its colour and consistence: thus it presents every shade, from the deepest and most intense black to a nearly white tint. Its consistence is sometimes that of pure water; in other cases it is like pitch ; and in others like glue or thick mucilage. The chemical composition varies, as well as the relative quantity of the constituents. In some cases there is a considerable predominance of the resinous principle; in some there is an excess of the yellow, while in others the cholesterine is the superabundant principle. In some cases it has consisted almost entirely of albumen and water, and this has been observed more especially in con- nection with a fatty state of the liver. It may be observed generally, however, that little has been as yet ascertained as to the causes of these alter- ations. It is this alteration in the proportions of the constituents which gives rise to the formation of biliary calculi. They consist of the inspissa- ted bile ; of its resinous matter; of cholesterine ; of picromel ; and of the phosphates. Calculi are never found of any one of these principles solely, but some one or other predominates, giving the character. They may, by obstructing the re- gular course of the bile, cause its absorption, and thus give rise to jaundice. Such are the anatomical characters and gene- ral nature of the principal organic diseases of the liver. We shall now proceed to their symptom- atology. Symptoms.—Perhaps there is no order of or- ganic diseases in the whole human frame in which symptoms assist less than in that under considera- tion. In some of the more acute forms of disease the symptoms are urgent; but, except in a few instances, they convey kttle or no information with respect to the nature or progress of the disease; and in the more chronic and obscure forms, irre- parable mischief is often established before the patient even suspects that there is anything wrong. Many of these diseases, and indeed all of them in particular cases, produce certain constitutional symptoms, which, taken into account with the Vol. III. —20 local ones, should any be present, will enable us to suspect, indeed confirm us in the belief of the existence of some sort of hepatic disease. But most commonly we obtain no farther instruction, and the real or precise nature of the disease re- mains in obscurity. We have nothing to do with inflammatory affections here: they have been al- ready considered. But as hyperaemia may be ac- companied with considerable enlargement of the organ, it will always be right in all suspected cases to examine the region of the liver, and as- certain whether any indication can be drawn from it. When it extends or projects considerably below the ribs, it can, unless some obstacle exist, be felt, and its size pretty accurately determined ; but in cases of ascites there may be considerable diffi- culty. The writer has often found the following plan succeed:—Place the hand upon the right side of the abdomen, and make the patient sud- denly turn upon his belly inclining upon the right side ; the enlarged liver will gradually sink through the fluid, and striking the parietes, will communi- cate a distinct impulse to the hand. Although this, should it occur, at once indicates the projec- tion of the liver and the probability of its enlarge- ment, yet the absence of this sign does not infer the converse, nor preclude the possibility of en- largement. Adhesions, for instance, by tying down the liver, will prevent the floating motion essential to the development of this sign. Percussion often enables us to determine the height, or rather the encroachments, made by the liver upon the capacity or boundaries of the tho- rax. By this means the margin of the liver may be completely and accurately defined, and a tole- rably accurate idea formed of its volume and ex- tent. There are no peculiar symptoms which will en- able us to determine the presence of anaemia of the liver. Induration and softening may in par- ticular cases be determined by the touch. Hyper- trophy and atrophy may be discovered,—the for- mer by the great increase of volume evident to the touch ; the latter by the diminution ascertained by percussion. With respect to hypertrophy, it may be observed that there is no accurate means of diagnosis between it and hyperemia. Tubercles may be felt in very thin persons, and if situated anteriorly; but there is no symptom peculiarly characteristic of them. The other diseases afford no symptoms by which they may be distinguished. Even gall-stones, unless passed by stool, afford no symptom by which their existence can be posi- tively determined. Gall-fetones passing through the ducts very often excite excruciating pain, cramps, sickness, vomiting, hiccup, &c; but these symptoms indicate but little while they last; and more frequently it is after the passage of the stone, ; and after the subsidence of the symptoms, that we are able to form some opinion as to their nature and cause. There are, however, certain general symptoms, which, when present, enable us to pronounce pretty positively as to the existence of hepatic dis- ease, though they will not assist in determining its nature. These are dropsy, certain forms of indigestion, and jaundice; subjects already fully treated of in different parts of this work. LIVER, (DISEASES OF THE) 154 - - , • i Tt m,i=t hi* evident, however, that we posseie no Other functions, as the respiration, circulation, » "^^^ mails' of determining the those of the tongue, skin, and urinary apparatus, i certi ,. . .iU _u. , —the last especially, become deranged. The re- spiration and circulation merely present the com- mon indications of irritation—a hurried or acce- lerated action. The tongue is generally coated, and commonly furred. A disagreeable taste is felt in the mouth, and eructations take place. What is brought up by eructation exerts various effects. Sometimes it is bitter, cutting, acrid, even excoriating the lining of the pharynx. This in general depends upon over-acidity, or upon chlorine. The fur on the tongue is yellow; some- times moist, sometimes dry; sometimes perma- nent, and in some cases it appears only in the morning, disappearing in the course of the day. The skin may be hot and dry, parched and rough; or it may be too relaxed, giving rise to cold clammy sweats. There is no excretion, not even excepting the alvine evacuations, which is more frequently de- ranged in the diseases of the liver than the urine. Thus, bile may be detected in the urine when no other irregularity is present, by the application of muriatic acid; it is sometimes necessary to con- centrate it by slow evaporation, when the addition of muriatic acid strikes a green colour. But organic disease of the liver is almost always attended with a deposition of the lithate of ammo- nia from the urine on cooling, of a bright pink colour. It receives this colour from the generation and intermixture of purpurate of ammonia. The urine when passed, though of a deep pinkish colour, is generally clear and transparent; but on cooling, the pink sediment separates ; and if col- lected upon the filter and examiued while moist, exhibits a remarkably deep pink colour. This sediment is re-dissolved by heating the urine. The urine, after filtration so as to separate the sediment, likewise presents a deep colour, owing to retaining a portion of the purpurate of ammonia in solution. In some cases the urine will remain of a deep pink colour, nor will any sediment sepa- rate. This arises from a deficiency of lithic. acid. The purpurate of ammonia has a strong tendency to combine with lithate of ammonia, which latter, being rather insoluble at the ordinary tempera- ture, precipitates on the cooling of the urine, car- rying down the purpurate along with it. But if there be a deficiency of lithic acid, no lithate of ammonia can be formed, and consequently no precipitate will take place. Hence the purpurate remains in solution, and gives this very deep pink colour to the urine, and which remains on the cooling of the urine without the formation of any precipitate. (Vide Prout, p. 125.) "The most perfect specimens of this kind of sediment which I have ever seen," says Prout, « were obtained from the urine of dropsical individuals; they occur nature of the morbid condition with which we have to contend. And, indeed, even if we could, in the present state of our therapeutical knowledge, it would afford no guide to the adoption of any special mode of treatment. Treatment. — In considering the treatment applicable to the organic affections of the liver, h will be useful to arrange it under two heads- general and local; understanding by the first, those means which act on the system generally; and by the second, those which are supposed to act by some particular local derivation. General Treatment. — The first of this ordet which naturally comes under consideration is bloodletting. As the general circulation not only frequently produces, but afterwards tends to keep up the state of hyperemia, or one of irregular vas- cularity in the liver, the means of controlling this function naturally presents itself as the most effec- tual as well as the most powerful of affecting a condition depending upon it. There are several points of view, however, in relation to different objects, in which bleeding may be considered. If the substance, or rather the vessels of the liver be gorged, bleeding generally, according to the cir- cumstances, will be advisable. This means, also, will be applicable in what may be termed conges- tion, in which the capillary trunks are distended. Bleeding acts, not by abstracting blood from the distended organ, but by reducing the force of the circulation—the vis a tergo, as it is called—and, consequently, lessening the quantity of blood di- rected to the part, as well as the impetus with which it is driven. An active state of the bowels will also prove beneficial; and the choice of the purgative will often be a consideration of some moment. When the object is to prevent the irritation arising from faecal accumulations, those purgatives should be selected which merely excite the bowels to propel their contents ; these are rhubarb, aloes, colocynth, brane in cases where the subjacent parenchyma is engaged, may be explained partly by the greater degree of motion which, in consequence of the function of respiration, the two pleural surfaces are exposed to; as in this way the parts are not only predisposed to inflammation, but a slight effusion of lymph may become an exciting cause of dis- ease by its mechanical action over an extensive surface. Again,—if, as there is great reason to believe, the air-cells are in reality white tissues, the propagation of inflammation from them to i similar structure ought more readily to take place than from the glandular acini of the liver to an essentially different tissue. The next stage of hepatic inflammation whick has been described is that of purulent formation or abscess ; but we believe that between this con- dition and the red softening of the liver there is an intermediate stage, in which the hepatic tissue is found of a yellow colour, exceedingly soft, and leaving a puriform exudation on the scalpel. Be- tween this state and the third stage of pneumonia. there appears to be a great analogy, as it is an in- terstitial suppuration immediately preceding the formation of abscess. In several instances we have observed this alteration to extend to some distance around an hepatic abscess, and in cases where numerous small purulent collections existed, the hepatic tissue which separated them had un- dergone this change. The tissue thus altered va- ries considerably in consistence, in some instances being almost semifluid, in others possessing a cer- tain degree of firmness. As yet this condition does not appear to have been recognised in the systematic works on pathology. Lallemand, in his « Lettres sur L'Encephala," speaks of a softening of the liver, in which, in consequence of severe inflammation, its tissue is reduced into a diffluent sanies of the colour of wine-lees ; but this condition is obviously different from that we have just described. Abscess of the liver, so common in India, is of rare occurrence in these countries. A few isolated cases are to be met with in medical records, but no series of cases was published as occurring in Europe until the appearance of Louis's researches on this subject. (Recherches Anatomico-patholo- giques. Paris, 1826.) Subsequently, the writer of this article, in conjunction with Dr. Graves, published several examples of this lesion. (Dublin Hospital Reports, vol. v.) Puriform matter, as the result of inflammation, is met with in the liver under several forms. We may find it, as it were, infiltrated into the hepatic tissue, as described above,—a condition to which the name of yellow softening of the liver may to given; it may occur in numerous minute il> LIVER, (DISEASES OF THE) 161 scesses; or, lastly, it may form one or more large collections of matter, in some cases encysted, in others bounded only by softened and yellow he- patic substance. These collections of matter are generally isolated, though in a few cases they have been found to communicate by fistulous passages. As yet we are not fully aware of the circum- stances which dispose to the formation of a cyst around these puriform collections. The more chronic the abscess, the greater will be the likeli- hood of a cyst existing, but it will often be found even in recent cases. We have seen these cysts under very opposite circumstances. Thus, in a case which occurred in the Meath Hospital, where, after acute hepatitis, the patient sank with suppu- ration of the liver, we found numerous abscesses, some the size of an orange, others that of a hazel- nut, the smaller being encysted, the larger not so. In another case, however, the reverse of this was observed. A patient had laboured under gastro- enteric fever for some time, when attention was directed to his liver, from his complaining of pain in that situation. The organ was then found en- larged, and it soon became evident that matter was forming. The patient died, and on dissection, a vast abscess in the right lobe, capable of containing several pints, was discovered : this was encysted, while in the remainder of the liver were numerous small abscesses, only separated by softened hepatic tissue. In another case, the particulars of which we shall detail hereafter, a very chronic abscess, communicating with the duodenum, existed in the right lobe, while a recent one, which had opened into the peritoneal cavity, was found in the left. In the first abscess, which had existed under our observation for two months, we found the cavity empty, and lined with a strong semi-cartilaginous membrane, of a dark greyish colour; while in the second there was no cyst whatever, its parietes being formed of yellow softened hepatic tissue. The last case which we shall notice on this sub- ject is that of a woman who sank under a very chronic abscess of the liver. Here the cavity was of enormous dimensions, and presented an imperfectly formed cyst, most developed where the parietes of the abscess were thinnest—that is to say, immediately under the serous covering of the convex surface. In the more deep-seated parts it could hardly be detected. The appearances of structure of these cysts are various. In some cases we only observe a pseudo- membranous layer, of a line or two in thickness, yellowish white, and resembling semi-concrete pus. In other cases the cyst appears organized, and may strongly resemble a mucous membrane; pre- senting villosities more or less completely devel- oped, which we can easily demonstrate by im- mersing the part in water. A third variety pre- sents the lining membrane of a reticulated struc- ture, for which the name of fibro-mucus has been proposed ; while in the last species the membrane j is semi-cartilaginous, of an iron-grey colour, and very similar to the investment of chronic tubercu- lous cavities in the lung. Nothing can be more various than the size of these abscesses. We have seen them so large as to be capable of containing four pints, and, on the other hand, they may be so minute as to represent suppurated tubercles, from which indeed it is Vol. III. —21 o« sometimes difficult to distinguish them. The surrounding hepatic tissue is generally in a state of red or yellow softening, but cases are on record where it has been found perfectly unaltered ; in these the disease was generally chronic. The same variety is observable in the nature of their contents. In all our cases, but with one exception, the matter was healthy, though sometimes mixed with portions of softened hepatic substance. In the case of exception, in which the operation of opening the abscess was performed successfully, the matter was of a dirty green colour, and mixed with sanious fluid. Andral states that in all the cases in which he found puriform matter in the liver, it was white and consistent, like the pus of a phlegmon, and that those who have described it as similar in colour to the lees of wine have con- founded other diseases, particularly the occurrence of encephaloid matter, with the inflammatory sup- puration. In warm climates, however, great va- riety is observed in this respect. « The matter," says Mr. Annesley, " contained in an abscess pre- sents various appearances. In some it is a thin, watery pus; in others, it is thin, watery, and with thick curd-like clots floating in it; in many cases it is perfectly purulent, and of varying degrees of consistence. As respects colour, there is also considerable difference; most frequently the matter is of the usual yellow colour. Some- times it presents a yellowish-brown or sanious tinge, and occasionally a greenish-brown or green- ish-yellow hue; sometimes it is watery or reddish brown; at other times it is observed of a creamy consistence, and nearly white. (Op. cit. p. 533.) It is to be regretted that the relations which exist between the vessels of the organ and these collections of matter have not as yet been made the subject of any accurate investigation. We cannot find any instance recorded, where, as in tu- berculous and other cavities in the lung, vessels were found traversing the puriform collections. They have been observed, however, forming pro- jections on the internal surface of the cysts ; but when we consider the vast size to which hepatic abscesses may attain, the inquiry as to what has become of the vessels becomes a matter of extreme interest, and in the present state of pathological anatomy offers a new field for inquiry. The abscess once formed may open in a great variety of situations both internally and externally. Of the internal openings we have witnessed the following examples :— I. perforation of the dia- phragm and communication with the lung; 2. communication with the duodenum; 3. perfora- tion of the peritoneum, and effusion into the ab- dominal cavity. The first of these terminations appears to be a not unfrequent and perhaps the most favourable of the internal openings of the abscess. Many patients have recovered where this lesion undoubt- edly occurred, as indicated by the fact of their presenting all the symptoms of hepatic abscess, both constitutional and local, which subsided upon the occurrence of a sudden and copious expecto- ration of purulent matter, which had not been preceded by any symptoms of pulmonary disease. We have known of cases where pressure exercised on the hepatic region was immediately followed by a free expectoration of pus. The easy exit of 162 LIVER, (DISEASES OF THE) the purulent matter, the result of its entrance into he has met with several cases of these cicalricei the Lnchial tubes, is in all probability a princi- in India. There ,s a form of disease whichu pal reason why this termination of the disease very liable to be confounded with hepatic ab«e* should be so often favourable. The abscess may as it has many symptoms in common with thistf fection ; we allude to a circumscribed inflammation and suppuration in the parietes of the abdomen, immediately over the liver. The disease sets in with fever, pain, tumefaction, and tenderness in the affected part; and, in addition, we have many open either into the right or left lung; and though there are some cases where the pulmonary pleura was not perforated, yet the communication with the pulmonary parenchyma and bronchial tubes is much more frequent than the formation of an empyema,—a circumstance explicable by the great tendency to adhesion presented by the pleura. Dr. Smith, an American writer, details a case where the hepatic abscess opened into the pericar- dium. The liver, which was almost entirely oc- phragmatic pleurisy cupied by an enormous abscess, adhered closely to the upper portion of the diaphragm, through which the opening between the abscess and the pericardium existed ; the pericardium was in- flamed, and contained about two pints of a puru- lent liquid similar to that which existed in the liver. It would appear, then, with respect to the tho- rax, that the abscess may open into the lung, pleura, or pericardium. Of these, the first is by far the most frequent. With respect to the abdo- men, the abscess may communicate with some portion of the gastro-intestinal tube, the perito- neal cavity, the gall-bladder, the vena cava, or kidney. In the cases where the opening has taken place into some portion of the digestive tube, its seat has been in the stomach, duodenum, or colon. Lastly, the abscess may open externally in a great variety of situations upon the abdomen, and also on various places on the side and in the ax- illa. When the opening takes place externally, it is seldom by a direct, but commonly by a sinu- ous and fistulous passage. Louis, in his Recher- ches Anatomico-Pathologiques, declares that he has never yet known of the occurrence of a cica- trix in the liver, the result of a cured hepatic ab- scess. We feel satisfied that this is a pathologi- cal appearance rarely observed in the dissecting- room,— a circumstance to be explained by the rarity of the disease in this country and its general fatality. In one case, however, we have witnessed this rare appearance. A patient who had been a soldier in the East-India Company's service, and who had, while in India, suffered from an attack of hepatitis, accompanied, as he described, by great tumefaction of the liver, died in the Meath Hos- pital of a chronic enteritis. On dissection the right lobe of the liver was found greatly dimin- ished in volume; while in the centre of its con- vex surface existed a very deep stellated depression, around which the hepatic tissue was puckered, rising in the form of crests with intervening sulci of nearly an inch deep. From the centre, which was occupied by a mass of cartilage nearly the size of a walnut, emanated prolongations of thin plates of cartilage, answering in number to and of the constitutional symptoms of hepatitis. In one case, which occurred in the Meath Hospittl, a slight jaundice existed for several days, analo- gous, in all probability, to that arising from die- These cases are genersHj of little severity as compared with true hepatitli, Matter forms speedily under the integuments, and, on this being evacuated, the patient rapidly reco- vers. In a case, however, which we have wit- nessed, the disease proved fatal under very remark- able circumstances ; we shall therefore notice it st greater length. A woman aged twenty-three, who had laboured under amenorrhcea for twelve months previously, was attacked with cough and hemoptysis, followed, after some days, by fever, pains in the back and limbs, and prostration of strength. Soon after this she complained of pain in the right side of the chest and hypochondrium, increased by coughing, pressure, or motion. She had a distressing short cough, with yellow tena- cious expectoration. The inferior portion of the right side of the chest sounded dull, and the re- spiration in this situation was almost inaudible except when she made a forced inspiration. The symptoms having continued for about a fortnight, an uncircumscribed puffy tumour made its appear- ance over the lateral portion of the liver; the he- moptysis returned, with a hard teasing cough,but the fever disappeared ; poultices were diligently applied to the tumour, which rapidly enlarged end presented evidences of extensive suppuration. On the thirteenth day after its appearance it was opened by means of an abscess-lancet, when a great quantity of matter mixed with blood wis discharged ; at this time the spitting of blood ceased. In about three weeks, however, the ab- scess again appeared, and rapidly increased to j size much greater than its former dimensionspt was again opened, and a large quantity of puru- lent matter given exit to. On the next day the abscess presented the appearance of an enormous anthrax, with edges about two inches high, from which a quantity of whitish slough could be de- tached by pressure; the patient was now emaci- ated, had diarrhoea, with cough and sanguinoku: and puriform expectoration. We endeavoured to trace the extent of the disease by introducing a probe; but although this was found to pass ei- tensively under the muscles and cellular substance, yet it could not be introduced either into the tb* , racic or abdominal cavity. After some tim« rt forming the base of the sulci which appeared on ! was found that when the patient coughed, or took his case we are not able to A*„_ > a deep inspiration, air escaped with great violence case we are not able to deter. mine by what aperture the contents of the abscess had been evacuated, but in all probability it was through the duodenum. The appearances on dis- section in this case were almost identical with those in a case of cicatrices of the liver, of which Mr. Annesley gives a beautiful drawing, (see plate 15 of his book.) This gentleman states that from the base of the ulcer, towards the upper por- tion of which a circular fistula, through which J probe could be passed, was observed ; through this the probe passed for about three inches, when it met with a solid resisting body. The inn* mammary region sounded clear on pcrcnsei» Examined by the stethoscope, the respiration t» LIVER, (DISEASES OF THE) 163 cavernous, and accompanied during inspiration by a sound like the tick of a watch. When the pa- tient coughed or made a forced inspiration, a loud guggling was audible. There was no metallic tinklina, bourdvnnement, or pectoriloquism; but the voice resounded strongly from the sixth rib upwards, while anteriorly and posteriorly the re- spiratory murmur appeared natural. She died on the following day. Dissection.—Great emaciation. The external sore extended from the sixth to the tenth rib : it j was about four inches in breadth. Between the eighth and ninth ribs the fistula was plainly ob- servable. On opening the abdomen, the serous membrane was found healthy, with the exception of that portion which covered the liver laterally and superiorly. Here the liver adhered to the diaphragm. On the centre of the convex surface of the liver j we found the base of the abscess formed by a cir- cular portion of thick, false membrane, of about two inches in diameter, external to the hepatic i peritoneum, but producing a depression on its i surface. The costal portion of the diaphragm, for i an extent corresponding to the base of the abscess, was destroyed, but adhered round its edges. This abscess communicated with the lung by a perfora- tion through the diaphragm of about the same size as the exlernal fistula, which led into an abscess in the lower lobe of the right lung. This was narrow, elongated upwards, and presented many of the characters of pneumonic abscess. It had no lining membrane, and communicated with numerous bronchial tubes. Around it the pulmo- nary tissue was of a greyish-white colour, softened but not granular. The diseased portion did not terminate by any distinct line, and occupied about two-thirds of the lower lobe, which was univer- sally adherent to the diaphragm, and for about three inches to the costal pleura ; the remainder ! of the lung was healthy. The mucous membrane of the stomach was pale and soft; the lower por- tion of the ileum red, and presenting some aph- thous ulcerations: the mucous membrane of the colon was covered with fungous elevations, and numerous aphthous ulcerations. (Meath's Hos- pital Reports.) In this case the diseased action had in all pro- bability a double seat from an early period, namely, the lower portion of the lung and the integuments over the liver; it is remarkable for the double per- foration of the diaphragm through its costal and thoracic portions, and for the direct communica- tion made by the latter with the substance of the lung : the pleural and peritoneal adhesions pre- vented the escape of the matter either into the thoracic or abdominal cavity ; a circumstance illustrative of the powers of nature in availing herself of diseased action to promote an ultimate cure. Some authors have described gangrene as a result of hepatic inflammation ; but facts are still wanting for the elucidation of this subject, and there can be but little doubt that, if it ever does occur, it must be a circumstance of extreme rarity. On this subject we shall quote from Mr. Annes- ley:— " Gangrene has been remarked by many writers and teachers as one of the terminations of acute inflammation of the liver; but although we have observed this disease, and made post-mortem exa- minations of it, the number of which certainly has not been exceeded by any other inter-tropical practitioner, we have never spen a single case of gangrene of this viscus. We are inclined to believe that the appearances that have been taken for gangrene have been merely that black, con- gested and softened state of the organ which is sometimes observed in the more acute attacks of the disease, supervening to congestion, or at least this state of the viscus having speedily run into gangrene after the death of the patient; and therefore, if gangrene had actually existed at the time of dissection, it is to be considered as a con- sequence of death rather than a termination of the disease." (Op. cit. vol. i. p. 435.) In the works of the modern pathological ana- tomists of Europe, the same infrequency of gan- grene of the liver is observed; so that we may conclude that both in warm and temperate climates the termination of hepatitis by gangrene is of extreme rarity. Andral relates one decided case of gangrene of the liver, where the disease sur- rounded an abscess of the left lobe, and states that this is the only instance he has seen of gangrene of the liver. When we reflect on the vast num- ber of dissections which this great pathologist has made, the fact of his having seen the disease but once is a decided proof of its rarity. Here is another circumstance in which the pathological relations of the liver differ remarkably from those of the lung, as, in the latter viscus, gangrene is a not unfrequent occurrence; but when we consider the greater liability to a stasis or effusion of blood in the pulmonary parenchyma, as compared with the hepatic, and also that in the lung the diseased portion is exposed to the action of air, we may find in these circumstances an explanation of the fact. The effects of chronic inflammation on the liver are exceedingly various, and its results greatly influenced by the constitution or habit of the patient. Among them may be enumerated the different forms of hypertrophy, either partial or general, either of the red or white substance, or of both; induration; scirrhous or tuberculous tumours; and hydatids. We are far from believ- ing that these latter lesions are always the result of an inflammatory process; as there is undoubted evidence that these new tissues may be the result of a lesion of secretion and nutrition, not induced by any previous irritation of the part; while, on the other hand, cases are on record where these different diseases appear to have been first brought about by an acute or chronic hepatitis. The fol- lowing observations by Andral on this subject are highly philosophic :— " There is scarcely one of the alterations of the liver which have been described which has not been designated by the name of hepatitis. In my opinion, there is hardly one of them which may not be the result of an irritation whose first effect was to cause an hyperemia of the liver. For example, four individuals receive an external injury on the same region of the liver : in one an abscess is developed in the liver; in the second this organ becomes cancerous; in the third it becomes filled with hydatids; and in the fourth it 164 LIVER, (DISEASES OF THE) is atrophied. In all these four cases irritation haTe7pected when we recollect the general cornplic been manifestly the point of departure: but what tion of hepatitis with gastro-.ntestinal disea* has been its mode of action ? It has deranged the ! (See Castro-Enteritis.) normal nutrition of the organ; there its influence ' Acute hepatitis may be generally descnbed a, is confined: the predisposition of the individual , commencing with that group of symptoms ind.ca- has done the rest. On the other hand, I do not! tive of inflammation m the digestive system, i„ know an alteration of secretion or nutrition of the : other words, the patient at first appears to be «t- liver, not even a collection of pus in its parenchy- | tacked with gastric or bilious fever, to which euc- ma, that can be considered as necessarily arising from an antecedent process of irritation. I do not j know one of which we can say that its formation has been necessarily preceded by a hyperemia. What, then, does the word hepatitis express? Nothing more than the common link by which | the different lesions of secretion and nutrition of | the liver are often united. But this link is neither constant nor necessary ; and if we have seen a case where an hyperemia of the liver by external violence has been followed by the formation of hydatids, I may cite many other cases where nothing has demonstrated a similar point of de- parture, and where, from analogy, we would arrive at an opposite conclusion, and admit that the de- velopment of these entozoares is found connected with a diminished activity of the normal nutrition of the liver. (Precis d'Anatomie Pathologique, torn. ii.) Observations are still wanting to establish the exact relative frequency of suppuration as the re- sult of hepatitis in its acute and chronic stage; j there can be little doubt, however, that this lesion is much more frequently the result of an acute j than of a chronic inflammation. j With respect to the frequency of peritoneal ad- hesions it may be stated that these, which we have seen to be by no means constant in the acute dis- j ease, are commonly met in chronic hepatitis. In this disease the convex surface of the liver is gen- erally found adherent to the parietal peritoneum by strong und organized adhesions. On its con- cave surface we may also meet adhesions with several portions of the abdominal viscera, though, as far as we have seen, these are not so frequent nor so general as those of the convex portion. Symptoms of Hepatitis. — Inflammation of the liver has Ion ceed, sooner or later, symptoms of the hepatic dis- ease. There is often then high fever, the type being generally more inflammatory and less typhoid than that which results from a simple gastro-ente- ritis. The pulse is more frequently strong and full; there is thirst, a furred and yellowish tongue, and frequently vomiting, sometimes of a bilious, at other times of a dark-coloured matter. The bowels are commonly irregular or costive, and the discharges present a great variety of appearance. according as the biliary secretion is more or less affected, and also according to the degree of com- plication with gastro-intestinal disease. The urinary secretion is also affected, being almost always scanty and very high coloured. In addition to these symptoms we have the local indications of hepatitis, which are, principally, pain, tenderness, and tumefaction. The pain is felt in various situations, and occurs with various degrees of intensity. In some cases the patients describe it as a stitch in the side, aggravated by respiration or motion; in others the pain occurs about the cartilages of the lower ribs, or it may be felt in the lumbar region. Much has been written about the occurrence of pain in the right shoulder in cases of hepatitis ; from our experience we would say that this is an extremely rare symptom, and one by no means pathognomonic of the dis- ease, an opinion borne out also by the experience of Dr. Mackintosh (Elements of Pathology and Practice of Physic, vol. i.) in those countries, and of Andral in France. (Clinique Medicale, Mala- dies de l'Abdomen.) There can be no doubt that practitioners are often misled from attaching an unmerited degree of importance to the presence or absence of this symptom. Generally speaking, the pain is more acute when the inflammation is superficial,—a circumstance illustrative of thege- been described as occurring under two forms, the acute and chronic,- but al- though numerous cases will be met with where it j neral law, that in parenchymatous inflammations would be difficult to declare to which of these , the pain is more severe when the disease ap- species the disease belongs, yet in a practical point proaches or involves the surface of the organ. of view the division is convenient. Let us ex- j The symptom which we regard as next in im- amine the symptoms, progress, and termination of ' portance to the pain is the tumefied and tender the first or acute species. Acute Hepatitis.—In the different elementary works on the practice of physic, the symptoms of this disease are described as occurring in a manner much more constant than the state of the science condition of the organ. When the belly is flaccid and the intestines are empty, there is seldom much difficulty in detecting the hepatic enlargement. We then generally observe the right hypochtjn- drium and the epigastric region full, and the i can permit us to believe, and in this way the ! of the liver can be felt descending' more or less student is misled, and gets a very false and con- ' traded view of the affection. In fact, there is no one symptom mentioned that may not occasionally be absent; and, on the other hand, all may arise from other causes besides hepatitis. The symp- toms may be considered as local and general; the local being, principally, pain, tenderness, and tu- mefaction ; the general, fever, and lesion of the digestive and in some instances of the nervous and respiratory systems. Of these, the first two, namely, fever and lesion of the digestive function' below the costal cartilages. Sometimes the ribs appear tilted out, but the intercostal spaces pre- serve their relative positions with respect to them; a point of great importance in the diagnosis be- tween hepatic and pulmonary diseases. But where the belly is distended by either fiecal matter or air, it becomes extremely difficult to ascertain the enlargement of the liver. In such a case we would always recommend that a dose of opening medicine should be given, followed after some time by a purgative injection, after the operation of are by far the most frequent, a circumstance to be , which the examination of the hepatic region tf LIVER, (DISEASES OF THE) 165 be greatly facilitated. We shall also derive im- portant information by the use of mediate percus- sion by means of the pleximeter, as recommended by M. Piorry, from whose recent work we shall quote. " In some acute cases of hepatitis, or rather in sanguineous congestions of the liver, it has been easy to demonstrate, at the Salpetriere, the Pitie, and at the Hotel Dieu, that the liver is susceptible of great increase of volume, and that the dimen- sions of this gland diminish rapidly after a copious bleeding, and sometimes also by strict regimen, which by itself produces a loss of blood. The diminution of the hepatic organ varies from one to three inches, from above downwards, in the twenty-four hours ; this is still greater in propor- tion as the blood drawn is more considerable. Not only has this fact been observed with old men in whom the venous circulation, embarrassed by dis- ease, of the heart, and particularly its weakness, explains the tumefaction of the liver, but also in adults, in cases of plethora and acute fevers. I could easily accumulate twenty observations to support this proposition. M. Vidal, one of the house pupils connected with my attendance, has just related to me three most remarkable facts taken most carefully. I shall confine myself to the following : A young man discharges a loaded pistol direct against the region of the liver; the ball, however, does not penetrate, which singular fact may be attributed to the presence of air be- tween the muzzle of the piece and the ball, the pistol being applied to his clothes so firmly as to stop up the muzzle: his clothes are, however, torn, and the foreign body, after having violently con- tused the skin, falls at the feet of the wounded man. The first few days no accident of import- ance occurred; the circumference of the liver was bounded by a black line. The fourth day there was fever, flushed face, and dyspnoea very intense: this was referred to the liver; this organ above and below exceeded by an inch or more the former line of demarcation. A copious bleeding was tried ; the next day the liver had resumed its former dimensions, and the severe symptoms disappeared. The cure was rapid. (Piorry, du Procede Ope- ratoire, etc. Paris, 1831.) In using the pleximeter we should employ it over the epigastrium and hypochondrium, and also over the lower portion of the chest both anteriorly, laterally, and posteriorly. By this means, the ex- tent of the hepatic tumefaction can be generally determined with ease. In some instances the tumefaction is more evident in the superior, in others in the inferior portions of the liver; when, however, the belly is much distended, this mode of observation is liable to many difficulties: thus, when the intestines contain much solid and fluid matter, we cannot estimate the extent of dulness inferiorly ; and on the other hand, when they are distended by flatus, the liver is pushed upwards, under which circumstances the dulness of the lower part of the chest ceases to be a measure of the hepatic tumefaction. Jaundice has been described as an attendant on hepatitis, but it is not a constant symptom. The patients have generally a slightly yellowish tinge, particularly in the face, similar to what is observed in gastric or bilious fevers, but very different from I true icterus. In none of the cases observed by us at the Meath Hospital was there jaundice; and Andral relates numerous cases of hepatitis where this symptom was absent: it may, however, occur in acute hepatitis ; but facts are still wanting to explain its absence in some cases, and its presence in others. Of one fact we are certain, that jaundice, when induced by inflammation, is much more frequently the result of a duodenitis than of an inflammation of the liver. From the known effect of a duodenitis, simple or complicated with gastric inflammation, in the production of icterus, (Marsh, on Jaundice, Dublin Hospital Reports. Broussais, Commentaries, &c.) it becomes an in- teresting question to determine how far the com- | plication of gastro-intestinal inflammation in he- patitis may act in producing the symptom of jaundice. The following table of cases, taken I from the writings of Andral, Louis, and from the report of the Meath Hospital, may assist in throw- ing some light on the subject. The first column | states the condition of the liver, the second that of the gastro-intestinal apparatus and ducts, and i the third that of the skin. State of the liver. Acute hepatitis.......... Red softening........... Red induration.......... Numerous abscesses..... Abscess............... Ditto................. Ditto................. Hepatitis with tumefaction Hypertrophy........... Vast abscess............ Numerous small abscesses. Ditto ditto.......... Ditto Ditto Ditto Ditto Numerous abscesses Hypertrophy...... Numerous abscesses Ditto ditto..... Vast abscess....... Digestive tubes and ducts. Healthy ; ducts free.......... Healthy ; ducts free.......... Ditto ditto.............. ditto.............. ditto............. calculus........... healthy............ Chronic gastritis............ C Chronic gastro-duodenitis; ducts ~) I free.....................5 Gastro-enteritis; ducts healthy. Slight enteritis; ducts free .... C Gastritis ; gall-bladder atrophied; (_ calculus in cystic duct...... Colitis ; ulcerations of gall-blad- der ..................... Chronic gastro-duodenitis..... Chronic gastro-enteritis; duode- um healthy............. Gastritis................... Ditto...................... cChrc I ni Skin. Jaundice. Jaundice (slight). Jaundice. Jaundice. Jaundice. Jaundice. Jaundice (slight). Jaundice. Jaundice. Jaundice. Jaundice (slight). Jaundice (deep). Jaundice. No jaundice. No jaundice. No jaundice. No jaundice. 166 LIVER, (DISEASES OF THE) State of the liver. Abscess and gangrene — Abscess.............. Chronic abscess in right . Acute ditto in left lobe..... 5 Vast hepatic abscess .... Numerous abscesses .... Red softening......... Digestive tubes and ducts. Skin. No jaundice. ^' '', ' '.'■ No jaundice. Duodenitis.........;;...... c No jaundice, (slight yellow- \ Chronic gastro-duodenitis..... ^ ncss at trie commencement) dice. Healthy................... NT° Jaun ,. Colitis.................... No jaundice. Gastro-enteritis.............. No jaundice. It is obvious, from the inspection of this table, that we cannot arrive at any explanation of the presence or absence of jaundice in cases of hepatic inflammation, from the consideration of the cir- The indications of resolution are, in the first in- stance, the subsidence of the fever, the gastric symptoms, and the pain : this is followed by the disappearance of the tumefaction, which, though cumstance of gastro-intestinal complication. We ! generally the last in the order of symptoms, onei, see here cases of hepatitis with jaundice, in which \ occurs with great rapidity. The infra-mammary the digestive tube was free from disease, and the same symptom with gastro-intestinal inflamma- tion ; and, in the cases of hepatitis without jaun- dice, the tube was healthy in some and diseased in others. We may remark, while on this subject, that in hepatitis the biliary secretion is variously affected. In some it appears to be suspended, while in others, even after extensive suppuration of the liver, the gall-bladder has been found filled with healthy bile. We have observed these facts repeatedly in the Meath Hospital. Thus, in a case where a great number of abscesses were formed, the gall-bladder contained a perfectly transparent viscid fluid which did not coagulate by heat or the addition of nitric acid; the fluid was perfectly colourless, and in short presented all the characters of pure mucus. Notwithstanding this appearance of the contents of the gall-bladder, it is most remarkable that the intestines contained a quantity of yellow mucous 'and fsecal matter. In this case the mucous mem- brane presented indications of inflammation. In two other cases, where the most extensive destruction of the liver had taken place, the gall- bladder was found to contain a bile healthy to all appearance. In the first of these a chronic ab- scess existed in the right, and a recent abscess in the left lobe. In the second, the organ was com- pletely burrowed by numerous abscesses. In the different cases of hepatic abscess recorded by Louis, the greatest variety in the contents of the gall-bladder occurred. From these facts we seem justified in concluding that in acute hepatitis, and probably also in the chronic disease, we cannot form any exact diagnosis of the state of the liver from the appearance of the biliary secretions in the stools, inasmuch as in one case it is altered in its quality in a variety of ways, while in another, apparently the same condition of the organ, no perceptible change is observable. The truth is, that neither its presence, absence, nor alterations and postero-inferior portions of the chest recover their clearness of sound on percussion ; the dila- tation of the side is no longer observed ; the right hypochondrium and epigastric region lose the ten- sion and fulness which occurred during the acuity of the disease. Although a few cases of suppu- ration without perceptible tumefaction of the organ have been met with, yet from our own experience we would say that the subsidence of the swelling is one of the most certain indications of the reso- lution of the disease, certainly more so than the disappearance of the fever and pain. But when suppuration is to occur, we often find that the tumefaction, so far from diminishing, be- comes increased, and this at a time when the fever is frequently changed in character and assumes a hectic type. Shiverings, more or less severe, are observed, with or without perspirations; the pulse becomes small and rapid ; the countenance is pale, and a sour smell of the surface is perceptible. In one case we have observed a miliary eruption. There is generally a constant sense of weight and uneasiness in the right hypochondrium, and the pain has in some instances been found as it were to concentrate itself on a particular spot, probably corresponding to the principal collection of pus. After some time a fluctuating tumour may appear generally in the epigastrium or some part of the right hypochondrium, which is followed by dis- coloration of the integuments ; but in other cases no such occurrence takes place, and we must be guided by the history of the case and the consti- tutional symptoms in forming the diagnosis of suppuration. Should the tumefaction persist, with a fever either of the continued or remittent type, we may suspect the formation of matter. When, however, the abscess forms so as to be perceptible by manual examination, we may observe the fol- lowing conditions :—I, a generally enlarged state of the organ, in which, though no perceptible fluc- tuation exists, a doughy or boggy feel is commu- give us any data to enable us to conclude as to the j nicated over a greater or less portion of the stage, extent, progress, or termination of the in fiammation ; and it is plain that under these cir- cumstances the state of the stools will but little assist our prognosis. It is probable, however, that a very copious secretion of bile is more favourable than the contrary, as the inflammation of secern- ing organs is generally more inveterate when their secretion is arrested. When hepatitis is once formed, it may termi- nate by resolution or by suppuration ; or the irri- tation may continue in a modified manner, so as to be classed among chronic diseases of the liver. mour; 2, distinct tumefaction below the margin of the rib; 3, a tumour in the epigastrium; and, 4, a bulging of the false ribs, with more than usual fulness of the intercostal spaces. But it must be always borne in mind, that al- though the constitutional symptoms frequently undergo a remarkable change at the moment of suppuration, yet there are abundance of cases in which the change is scarcely if at all perceptible. To this we shall recur in speaking of the difficul- ties in the diagnosis of this disease. The constitutional symptoms which are of LIVER, (DISEASES OF THE) 167 most value are, the supervention of night perspi- : rations, shiverings, cold sweats, clamminess of the skin, and frequent fainting sensations. If this state has arisen in a case where it has been found impossible to affect the system with mercury, the diagnosis of abscess may be made with a great degree of certainty. In this last and most im- portant statement, the best East India practitioners agree, and we have heard one gentleman, who occupies a high rank in the service, declare that he never yet knew a case of abscess of the liver in which ptyalism was induced, even although the largest quantities of mercury had been ex- hibited. Mr. Annesley says, « that there can be no doubt that the system will not be brought under the full operation of mercury, or that ptyal- ism will not follow on the most energetic employ- ment of this substance, when abscess exists, al- though a slight tenderness of the gums will be produced by it." As far as our experience in the Meath Hospital has gone, we should say that the same circumstance holds good in the case of hepatic suppuration in these countries; but it is not peculiar to inflammation of the liver, as it is observed in other cases of intense visceral inflam- mation, in which, when ptyalism is induced, it is obviously the effect and not the cause of the re- duction of the visceral disease; and we have no doubt that, from not properly estimating this cir- cumstance, practitioners have erred with respect to the curative powers of mercury, and have done injury by the introduction of enormous quantities of this mineral into the system at a time when the violence of the local action prevents its specific and sanative effects on the economy. The terminations of these cases of hepatic ab- J scess are various. We have already alluded to the interna! openings of the abscess in describing the pathological anatomy of the liver in a state of inflammation. In these cases the diagnosis is to be made on the same principles which Louis has laid down in speaking of peritonitis from per- foration of the intestine: there is a sudden ap- pearance of a new train of symptoms, accompa- nied in almost all cases by subsidence of the hepatic tumour. Thus, when the matter makes its way into the lungs by the mechanism which we have before described, a sudden and copious expectoration of puriform matter has been com- monly observed : this is accompanied by a re- markable diminution in the hepatic tumour, i Should these symptoms arise in a case where previously there had been no evidence of disease in the pulmonary parenchyma, the diagnosis may be still more certain. We had once an oppor- \ tunity of making a stethoscopic observation of this most interesting lesion; the patient had reco- j vered from an attack of that violent gastric fever accompanied by yellowness of the skin which we have described in the article Enteritis, when he I again came under our care, labouring under symp- \ toms of hectic fever, which proved ultimately to proceed from hepatic suppuration. This patient had a constant dry cough, which led us to make repeated stethoscopic examinations without our being able to detect any disease whatsoever in either lung: in less than twelve hours after the last stethoscopic observation the patient was sud- denly seized with a feeling of suffocation, and began to expectorate large quantities of perfectly formed pus, of which in the course of the night he discharged upwards of a pint and a half. On the following morning the left lung, which the day previously had presented no morbid sign whatever either by the stethoscope or percussion, was found completely dull over the whole region of the lower lobe, with complete extinction of the respiratory murmur : there was no bronchial re- spiration, no resonance of the voice, dilatation of the side, nor displacement of the heart; nor was there any constitutional symptom indicative of either pleuritic or pneumonic inflammation. The patient continued to expectorate copiously for some days, and after the second day the morbid phenomena of the chest began to subside. We had, first, a mucous rattle audible at the root of the lung, which gradually extended over the dull portion, and was followed by a return of the re- spiratory murmur and resonance of the voice. This stethoscopic observation, for the accuracy of which we pledge ourselves, is explicable only by the sudden filling of all the bronchial tubes with purulent matter. Let us observe, first, the sudden supervention of dulness and absence of respiration in a patient whose chest a few hours before presented no morbid phenomenon; this is accompanied by a copious expectoration of puru- lent matter, and there are no constitutional symp- toms of pleurisy or of pneumonia. The absence of these symptoms is of great importance, be- cause if the disease had proceeded from either of these lesions, it must have been of extraordinary violence, and would have certainly been accom- panied by high constitutional and local symptoms. There was no dilatation of the side, or displace- ment of the heart, so that the diagnosis lay be- tween hepatization of the lung and the sudden filling of the tubes with pus ; but there was no bronchial respiration nor resonance of the voice, which would have occurred had it been hepatiza- tion, but which were absent because the large tubes were completely filled ; and further, during the recovery of the patient the phenomena of the voice were exactly the reverse of those in pneu- monic resolution. Thus, in the latter the reso- nance decreases, while in this case it increased;— in hepatization, because the air-cells recover their permeability, and the morbid subsides into the natural bronchophony ;—in the case under con- sideration, because the emptying of the tubes permitted the return of the natural resonance of the voice. The resolution of pneumonia is ac- companied by decrease of bronchophony, while in the case before us it was accompanied by in- crease. In the majority of cases the matter discharged from the chest consists of well-formed pus. In a case, however, reported by Annesley, the opening of an hepatic abscess was followed by a violent purulent and bloody expectoration ; the patient experienced a great sense of suffocation when he lay on his back, and on dissection a vast hepatic abscess was found communicating with the poste- rior portion of the lung. We have witnessed a case of the same lesion, in which, whenever the patient turned on the left side, a large quantity of purulent matter was dischaiged from the trachea. i It is hardly possible to confound this accident 168 LIVER, (DISEASES OF THE) with any disease of the lung, properly so called, particularly if by stethoscopic observation we have been satisfied of the previously healthy condition of the organ. The only cases which might possibly be confounded with it are the rare instances of the opening of an empyema into the lung, or the sud- den secretion of purulent matter in quantity by the bronchial mucous membrane, of which a few instances are recorded.* We have already spoken of the rarity of hepa- tic abscess opening into the general cavity of the pleura—a circumstance explicable by the adhe- sions which are formed between the two surfaces of the pleura, and which have the effect of direct- ing the matter into the substance of the lung. From the rarity of these cases, it is difficult to state the symptoms of this lesion ; yet in a case where a sudden occurrence of the signs of effu- sion into the pleura, accompanied by the disap- pearance of those of the hepatic abscess, were ob- served, the diagnosis might be made with a great degree of probability. A not unfrequent termination of hepatic ab- scess is by the establishment of a communication with some portion of the digestive canal. The stomach, duodenum, and colon, are the parts in which the communication has been most com- monly observed ; and the circumstances which appear to influence the point of communication are principally the situation of the abscess and the general volume of the hepatic tumour. When the matter makes its way into the stomach, a sudden vomiting of purulent fluid, with subsidence of hepatic tumour, has been observed. When, on the other hand, it opens into the intestine, we have a sudden diarrhoea, followed by the same phenomenon. From instances of recovery under these circumstances, it seems fair to infer that a cure by cicatrization of the opening is not unfre- quent ; but the opening may become fistulous, and continue until the fatal termination of the case. This occurred remarkably in a case the par- ticulars of which we shall just now detail, and which we before alluded to. Rupture into the peritoneal sac seems to be more frequent than the opening into the pleura, a circumstance to be expected from the smaller de- gree of liability of this membrane to form adhe- sions. When it does occur, we have violent peritonitis supervening; but the full evacuation of the abscess is not a necessary consequence. The following unique case is highly instructive, as illustrating the rupture of hepatic abscesses both into the digestive canal and peritoneum. A man, aged 39, was admitted into the Meath Hospital in August, 1828, labouring under hectic fever, with cough and nausea. He complained of great soreness from the fourth rib on the right side downwards. The hypochondrium was full and tender, and the side dilated one inch and a half, without distension of the intercostal spaces. Having recognised that the disease was hepatic, and suspecting that an abscess, deep-seated, had formed, we determined on performing the opera- tion, first proposed by Dr. Graves, of dividing the * See Pan Swieten, Comment, vol. iv. p. 60. Les Ephe- merides des cnrieux de la Nature. Baumts, Traite de la Pbthisie. Hippocrat. de morbus vulgaribus. JUndral, Clinique Medicale. abdominal parietes as far as the peritoneum, and keeping the wound plugged with lint. This was done, yet after six days had elapsed, no matter made its appearance. Soon after this a circum- scribed tumour, evidently containing fluid, sud- denly appeared between the median line of the epigastrium and the termination of the wound. It is important to remark that this tumour was not preceded by any local induration, but at once pre- sented fluctuation. In consultation, however, it was determined to open it cautiously by means of a lancet, when, in place of matter, there was a gush of dark-coloured bile : the tumour disap- peared, but fulness of the side continued. About four hours after this operation the patient ex. pressed a sudden desire to go to stool, and passed two copious discharges of purulent matter with bilious faeces. This was followed by remarkable improvement, and the tumefaction rapidly dimin- ished, so that in a few days all swelling of the right hypochondrium had disappeared. A diarrhoea, however, continued from the time of the disappear- ance of the tumour, and resisted every attempt to check it. Twenty-three days after the subsidence of the first tumour, a small hard swelling was ob- served in the epigastric region, about the size of an egg; this increased daily, and soon became fluctuating. On the thirteenth day after this, sudden and violent peritonitis set in, with subsi- dence of the epigastric tumour. He lived eight days longer, the diarrhoea continuing until his death. From considering the various symptoms in this case, we made the following diagnosis publicly, before dissection; viz. 1. that the gall-bladder would be found to have been punctured, but that from peritonitis not having set in on that occasion, it was probable that its fundus was adherent; 2. that a chronic abscess would be found in the right lobe of the liver, which was the cause of the first symptoms, and in all probability of the persistent diarrhoea, from a communication remaining open between it and some portion of the digestive tube; 3. that a recent abscess would be found in the left lobe, which had opened into the peritoneum, and had caused death by peritonitis. On dissection, the peritoneum was found of t deep-red colour, containing a quantity of serous fluid, in which was a large quantity of flocculi, forming masses having the consistence of jelly; the liver was generally adherent to the diaphragm and abdominal parietes, the adhesions of the right lobe being strong and ancient, those of the left soft and recent. In the left lobe an abscess of the size of an orange was discovered a little above its lower edge, and communicating with the peritoneal cavity by a fistulous opening, sufficiently large to admit a quill. In the right lobe we found I cavity of the size of an egg, empty, and lined with a semi-cartilaginous membrane of a dark iron-gTey colour : this communicated with the duodenum by an opening large enough to admit the finger with ease. The gall-bladder presented superiorly a spot exactly corresponding to the size and form of a lancet puncture, which was covered by a thin transparent membrane. (Dub- lin Hospital Reports, vol. v.) But hepatic abscess frequently proves fatal without any rupture internally or externally. In LIVER, (DISEASES OF THE) 169 these cases, as Broussais has well observed, the diseased action is seldom confined to the liver, but commonly occurs in some other organ, such as the gastro-intestinal mucous membrane, the lungs, or brain ; of these the first is by far the most fre- quent. The actual state of pathology, however, does not permit us to adopt the opinion of Brous- sais as to the constancy of this complication, but the fact of its frequency is well established, and becomes of great importance in practical medi- cine. In all the cases of abscess of the liver re- corded by Andral, there is but a single instance where the disease occurred without complication with lesion of other organs. Suppuration of the liver has occurred without any of the characteristic symptoms of hepatitis. Thus, in the twenty-sixth observation of Andral, numerous abscesses, with redness and softening of the hepatic tissue around them, were found, yet the patient never had pain or tumour in the region of the liver, nor was he jaundiced: in this case there was complication with acute pneumonia and gastritis. In another case, where a scirrhous state of the stomach existed, numerous partial in- flammations of the liver and an abscess were dis- covered ; the patient never had either icterus or pain either in the hypochondrium or right side of the chest. The same author details a case where an hepatic abscess with gangrene was dis- covered after death, and in which all the charac- teristics of an hepatic affection were absent. The patient laboured under a chronic bronchitis and gastritis. We have known two cases where nu- merous abscesses were found in the liver, and in which the symptoms were merely those of con- tinued fever, without any indication which could lead to the suspicion of the disease. Other in- stances might be quoted, but such cases are com- paratively rare, and should not discourage the student, or render him too sceptical as to the powers of diagnosis. In certain cases, the gall-bladder becomes dis- tended with bile so as to form a tumour in various situations along the margin of the liver, represent- ing in many particulars the phenomena of an hepatic abscess so completely, that the most emi- nent practitioners have been deceived in their diagnosis. It is extremely difficult to lay down rules by which this affection can be distinguished with absolute certainty. The obstruction of the ducts in most cases has been preceded by more or less of indications of hepatic disturbance, which it is impossible to say, did not proceed from dis- ease of the parenchyma of the liver. In the case which we have recorded, there was actually an hepatic abscess at the time when the distension of the gall-bladder occurred, and which was evi- dently its cause, so that in this case we had the local and constitutional symptoms of hepatic suppuration preceding the tumour, caused by the gall-bladder. In this case, then, the previous symptoms could only mislead us as to the nature of the tumour. We are not, however, aware of any other case where the tumefaction of the gall- bladder was preceded by an hepatic abscess. In the first volume of the Dublin Hospital Reports, a most interesting case of enlargement of the biliary duct is recorded by Mr. Todd. The Voi,. III. —22 p patient, a delicate girl, had been in bad health for some months previous to her death, during which she had had severe fever, with several relapses. When she was first seen by Mr. Todd, she was nearly insensible ; she moaned incessantly, and frequently screamed, as if seized suddenly with acute pain ; the skin was of a deep orange colour, and she was greatly emaciated. On examination, it was found that the abdomen was distended with fluid, and that the epigrastic and right hypo- chondriac regions were occupied by a tense swell- ing, which could be traced extending even below the umbilicus. A distinct fluctuation was per- ceptible at the most prominent point, a little below the ensiform cartilage, and a little to the right of the linea alba. This part was extremely sensible, and hence it was thought probable that a large abscess of the liver was here approaching the sur- face. With this impression, and anxious to afford immediate relief, Mr. Todd made an opening into the most prominent part of the tumour, when a thin fluid coloured with green bile escaped; a canula was then introduced with a view to pre- vent the escape of the fluid into the peritoneal cavity, when upwards of two quarts of a viscid green bile were discharged. After the operation, all the tumefaction of the abdomen had subsided, and no enlargement of the liver nor any other swelling could be detected. In the evening, how- ever, the belly became swollen, painful, and tense, and the patient died on the following day. On dissection, the peritoneum was found inflamed, and containing a serous and bilious fluid : the liver was perfectly healthy, and the gall-bladder was found empty and contracted ; but the hepatic and common ducts were found to be enormously distended, forming a sac, which still contained more than a quart of bile, and extending from the porta of the liver to the os sacrum, lying be- hind the duodenum, pancreas, and root of the mesentery, and stretching in a transverse direc- tion, so as to cover the anterior surface of the right kidney, and the greater part of the left. Andral relates several cases of distended gall- bladder forming an evident and fluctuating tu- mour in various portions of the abdomen. He has seen it, 1st, immediately below the cartilaginous portions of the right ribs ; 2dly, lower down in the hypochondrium ; 3dly, in the iliac fossa ; and, 4thly, in the epigastric region. In a case of aneu- rism of the hepatic artery, which we have lately observed, the gall-bladder formed a fluctuating tumour very near to the right ileum, and the biliary ducts were found in a similar state to that described by Mr. Todd, only distended to a less degree. We believe that in all the cases, with the exception of that which we have recorded, there was jaundice ; and it is probable that if the gall-bladder had not been punctured, and that the abscess had continued to press on the ducts, this condition would ultimately have been induced. In this case, also, it is very important to compare the appearance of the two tumours with a view to their diagnosis. That of the gall-bladder appeared suddenly, without being preceded by local pain or induration, but was at once fluctuating; that arising from the abscess of the left lobe was pre- ceded by pain and induration; and fluctuatioa 170 LIVER, (DISEASES OF THE) did not appear until some days after its occur- rence. This observation may be of utility in de- termining the point in future cases. Chronic Hepatitis—A great number of affec- tions of the liver have been classed under this general term ; such as induration, scirrhus, tuber- cle, hypertrophy, atrophy, &c, &c. In fact, we cannot say with certainty what the condition of the liver will be on dissection in a case where symptoms of chronic irritation have existed. We may, indeed, recognise an enlargement or an in- duration, but it appears rash to go farther than this. The liver, like other organs, however, being subject to chronic inflammation, we may recog- nise this condition, although we cannot say what particular alteration it may have induced. The disease may set in with attack of acute hepatitis, or may from the commencement pre- serve a slow insidious character. In some cases there is more or less of fever, while in others the patient is apyrexic. The principal phenomena are various derangements of the digestive func- tion, and it is often next to impossible to pro- nounce on the actual condition of the gastro-in- testinal mucous membrane. In fact, chronic dis- ease of the liver and of this surface are commonly combined. If, in addition to pain long continued in the region of the liver, increased by excitement, and accompanied by tenderness and tumour, we observe a sallow countenance, a dry skin, foul tongue, scanty and high-coloured urine, with oc- casional attacks of jaundice, we may safely make the diagnosis of chronic hepatitis. In the less acute forms of the disease the local symptoms of an hepatic affection are often very indistinct, and the case presents many of the usual phenomena of a chronic gastro-enteritis. In addi- tion to these, the pain about the right shoulder, when it does occur, the distension and oppression in the epigastrium and right hypochondrium, the bitter taste in the mouth, the sallow appearance of the countenance, the elevation of the shoulders, and the wasted state of the body, are the circum- stances which in warm climates are relied on as indicative of hepatic disease. It is stated that, when the surfaces of the liver are the seat of disease, the pain is more decided, and that, as the superior or inferior surface is chiefly affected, so in the first case the symptoms will be referred to the chest, and in the second to the stomach and bowels. An eminent writer says, that when the superior and exterior part of the right lobe is the seat of disease, the patient reclines with most ease on the right side, a drag- ging sensation being felt on turning to the left. From this sensation it is supposed that we may infer the existence of adhesions between the lobe of the liver and the right side. Nothing can be more various than the termi- nations of this disease which have been observed. In fact, every one of the known organic changes of the liver has been found in cases where the patient laboured under symptoms of chronic hepa- titis. Most of these certainly may be looked on as the results of the inflammatory action, the modifications in their nature being probably con- nected with the constitutional dispositions of the patient In fatal cases, death is induced by vari- ous circumstances. In some cases an acute hepa- titis supervenes upon the chronic, but in the m«. jority the patient is cut off in consequence of die- ease of other organs. He may be attacked by peritonitis, either in consequence of the rupture of an abscess or of the gradual extension of dis- ease to the serous surface: he may be attacked with enteritis or dysentery, which is a common termination in warm climates : pulmonary or cere- bral disease may set in; and dropsy, with or with- out an affection of the heart, is not unfrequcnt. The diseases with which chronic hepatitis has been confounded are principally the following: chronic gastro-duodenitis, scirrhus of the stomach, chronic pleurisy of the right side with empyema, and a neuralgic affection, of which the seat ap- pears to be in the hepatic plexus. In the articles Enteritis and Gastro-Eitts- ritis we have alluded to the great frequency ol the error of confounding the affection of the gas- tro-intestinal mucous membrane with that of the liver, and have dwelt on the injurious conse- quences of this mistake. W,ith respect to the diagnosis between this disease and chronic pleurisy with effusion, we would say that there is hardly a case where the tact of the practitioner is more requisite than in this. We will suppose that he is called to see the case for the first time after con- siderable enlargement of the organ has occurred. He will often find that the history of the case gives him but little assistance, as the two affec- tions are often accompanied by very similar symp- toms ; neither will he derive decided assistance from the stethoscope and percussion. In both cases we may have extensive dulness of the side, absence of respiration, resonance of the voice, or bronchial respiration. The side will be dilated in both, and the decubitus generally on the affected side. Neither will the existence of a tumour in the abdomen be unequivocal, as in the one case it may occur from hypertrophy of the organ, in the other from displacement. From our experience we should say that the indication which is the most unequivocal is drawn from the state of the intercostal spaces. When the side is dilated by a fluid, as in empyema, the spaces are raised either to a level with the ribs or even protruded beyond them, and the side has generally a smooth and rounded appearance. On the other hand, when the dilatation is produced by a solid tumour, such as an enlarged liver, the reverse of this occurs; the pressure being exer- cised on the ribs, these are pushed outwards, but the intercostal spaces preserve their relative posi- tions with them, and the side does not present any thing of the smooth and rounded appearand1 which we have described. (See Dub. Hosp. Rep. vol. v.) There are certain cases, however, where even this diagnosis is not applicable, such es where the patient is fat, the integuments cedems- tous, or the belly distended by fluid. Under such circumstances the difficulty of diagnosis is extreme. It appears to us that the attention of British practitioners has not been sufficiently called to the frequency of the neuralgic affection of the hvei which is commonly seen in hysterical subjects, and has been noticed by Andral in his Cliniquf Medicale. « We sometimes observe in the region of the liver severe pain, which cannot be accounted for after death by any lesion of the viscus or its LIVER, (DISEASES OF THE) 171 excretory ducts. These are cases of hepatalgia or hepatic colic. The circumstance just men- tioned, and, moreover, the nature of the pains, their intermission, and the state of good health which often exists in the intervals,—all lead us to believe that these pains have their site in the numerous nervous filaments which are distributed in the liver, and which are derived either from the pneumogastric or the great sympathetic." (Mala- dies de 1'Abdomen, t. ii. p. 26.) The persons in whom we have witnessed this affection were females. In some of these a deci- dedly hysterical tendency existed, while in others this disposition was scarcely if at all indicated. In one case the condition of the spine lately deno- minated " spinal irritation" was present. The principal symptom in these cases was a constant pain in the region of the liver, which lasted for years, and was subject to occasional and violent exacerbations from various causes, such as mental emotion, fatigue, over-excitement, derangement of the bowels, or the occurrence of menstruation. During the exacerbation the pain is excruciating, —to all appearance more violent than that in the most intense inflammation,—and is generally ac- companied with exquisite tenderness of the right hypochondrium. It has been stated to have been sometimes accompanied by a slight jaundice; but of this we never witnessed an instance, as, in the cases which we have observed, none of the usual symptoms of hepatic irritation, with the exception of the pain, existed. There was never fever, nor tumefaction, nor a bilious state of the urine, foul- ness of the tongue, thirst; nor were the alvine evacuations apparently affected, although the dis- ease had been present, for months or even years. Further intervals occurred during which the pa- tient enjoyed a respite from pain, and presented no local nor general symptom of hepatic derange- ment. The diagnosis of this disease is then to be drawn from the violence of the pain, which is greater than that of inflammation, combined with the absence of fever, tumour, and the other indi- cations of structural disease of the liver. We may also remark, that in several cases which have occurred under our observation the patients were subject to neuralgic affections in other situations, as the face or extremities: in one, severe dysme- norrhea had long existed. It is now some years since we were consulted in the case of a lady of luxurious habits and highly nervous temperament, who, while in India, had been attacked with pain in the region of the liver, which was supposed to arise from acute hepatitis. For this she was largely bled, both generally and locally, and brought under the influ- ence of mercury, without relief. She was ordered to return to England, and on the passage was several times bled and twice mercurialized with the same intention. Some time after her arrival in this country, the pain became again severe, and occurred with violent exacerbations. Each attack had been treated as if it had been one of acute hepatitis, she having been repeatedly bled, leeched, blistered, and mercurialized. Temporary relief used to be afforded by the bleeding, but the dis- ease constantly recurred; her constitution had become shattered, and she was constantly subject to the most violent hysterical paroxysms : the stomach had become so irritable that every thing was rejected, and the patient's sufferings were indescribable. Such was the condition of this lady when we were first called to see her; it was plain that the disease had resisted the most rigor- ous and long-continued antiphlogistic treatment. We found that there never had been any fever, that the right hypochondrium was perfectly supple, the lower part of the chest sounding clear, the tongue clean, the eyes and complexion clear, and the patient subject to neuralgic affections in other parts of the system. Under these circumstances, we determined on treating the affection as a neu- ralgia. Further bleedings were inhibited, contrary to the wish of the patient, who, as before stated, experienced temporary relief from them. She was put on a generous diet, sent to the country, and directed to use free doses of the carbonate of iron. This treatment proved perfectly successful, and in the course of a few weeks the lady was in the enjoyment of a state of health and comfort to which she had been a stranger for more than two years previously. We know of another case of a lady who had been actively treated for supposed hepatitis in the country without success. She was advised to come up to town to place herself under the care of physicians, for the purpose of undergoing a course of mercury. On examina- tion, her medical attendant could find no evidence of hepatic disease except the pain. She was also treated by the carbonate of iron with complete success. Since then we have known several cases where the error of confounding this affection with inflammation has been committed, — an error always full of danger, but in Great Britain pecu- liarly unfortunate, from the empirical and almost universal employment of mercury in all hepatic affections. We have at this moment under our care a most deplorable example of the effects of this error, where the most profound lesions of the nervous system have been induced by the long- continued use of mercury. Causes of Hepatitis. — The exciting causes of hepatitis may be enumerated as follows: resi- dence in a tropical climate, intermittent or con- tinued fever, gastro-intestinal inflammation, sup- pression of habitual fluxes, abuse of spirituous liquors, injuries of the side, wounds of the head, congestion from venous obstruction, suppression of cutaneous eruptions, exposure to cold, gall- stones, &c. Treatment. — When a patient has been at- tacked with symptoms of acute hepatitis, the dis- ease being still in its early stages, and no evidence of suppuration present, the treatment should be commenced by a free bleeding from the arm, which, if the subject be robust, and the inflamma- tory fever high, should be pushed so as to produce some effect on the circulation. It would be always well to see the patient again in the course of from four to six hours, when, if the pain and oppression should have returned, and the inflammatory fever again be lighted up, the bleeding should be re- peated without hesitation ; a less quantity of blood, however, will generally answer the expected pur- pose. The bowels should be opened by a free dose of calomel, followed by saline medicine, and assisted by a purgative injection. The patient will thus be brought into the state best adapted 172 LIVER, (DISEASES OF THE) for deriving advantage from local bleeding; and we would impress strongly on the mind of the practitioner, that, although the exhibition of mer- cury is sometimes indispensable, he must place his chief reliance on general and local bleeding, both as the surest means of arresting the disease, and of ensuring the beneficial action of mercury should its exhibition become necessary. In warm climates it has been observed that in some cases the opera- tion of bleeding is followed by faintness before a sufficient quantity is taken, and the blood is dark and grumous. In this case, as has been observed in other violent inflammations, (see Rush on the Yellow Fever,) the bleeding is soon followed by more violent excitement of the circulation, when a second bleeding is indicated, and the patient will bear the loss of a much greater quantity of blood; and this will then be found to present the huffy appearance in a much higher degree. The second bleeding also gives much greater relief to the patient. From our experience we would say that general bleeding has not the same marked influence over hepatitis that it has over peripneumony, but ap- pears principally useful in preparing the patient for local depletion, which seems to have the most direct influence on the disease. We have seen a case where upwards of a hundred ounces of blood were drawn at different times, and in which no apparent effect was produced on the inflammation until local bleeding was performed. In a robust adult not less than thirty leeches should be applied after the general bleeding, to the most painful part of the side, a measure which will be followed by still greater advantage if the bowels have been previously opened ; and to ensure this result, pur- gative injections should be used to assist the action of the medicine administered by the mouth. When the patient can bear it, the greatest ad- vantage will be derived from the application of a cupping-glass, fitted with an exhausting syringe over the leech-bites, by which means a much greater quantity of blood is obtained, and the sub- sequent oozing from the leech-bites generally pre- vented. As the blood flows, the exhaustion should be gently continued until the cup is full, when, if it is thought necessary to obtain more, the cup should be re-applied, and its margin surrounded with a cloth dipped in warm water; this causes a copious flow of blood. In all cases it will be well to avoid, as far as possible, the oozing hemorrhage of leech-bites, as this exhausts the patient without any correspond- ing influence on the disease, and keeps him in an uncomfortable state. It is much better to make several applications of leeches successively, and to arrest the hemorrhage after the leeches have fallen off, either by the cupping-glass or the appli- cation of styptics, of which the best appear to be the solid nitrate of silver, or the muriated tincture of iron. In the Meath Hospital the application of powdered alum has been found very beneficial. After the hemorrhage has been completely arrested, the patient will derive great advantage from the application of warm poultices of linseed-meal or bread and milk over the affected organ; these, however, must be made light, as their weight in some cases proves distressing. It has been the practice on the continent, and lately in Great Britain, to apply leeches to the anus in case of hepatic irritation, on the principle of depleting the system of the porta through ft hemorrhoidal veins. We believe that the only cases in which this practice would be decidedly beneficial are those where the hepatitis is compli- cated with dysentery, or where it has supervened on the suppression of a hemorrhoidal flux; but in no instance should we be content with this mode of local depletion, as it is decidedly inferior to the application of leeches over the affected organ itself. In the dysenteric complication to which we have alluded, which is frequent in India, Mr. Annesley has found decided benefit from the application of leeches to the os coccygis. The circumstances which point out that the general and local depletions have exercised a salutary influence on the suffering organ are the following:—the diminution of the inflammatory heat and of the oppression in the epigastrium and hypochondrium ; the subsidence of the pain and tenderness; and, lastly, of the tumefaction, which is to be ascertained by the touch and by percussion of the lower part of the thorax and abdomen. (See article Abdomen, Explanatios of.) Blisters may be now employed, but their use must never be resorted to while the inflamma- tory fever continues high, and they must be re- moved as soon as the patient begins to feel their stimulus. (See Derivation.) When the disease occurs in persons of a broken- down constitution, and particularly in those who have long indulged in ardent spirits, it is scarcely necessary to observe that we must be much more cautious in the use of the lancet, and trust prin- cipally to local bleeding and counter-irritation. After the employment of general and local bleed- ing, the production of ptyalism appears to be the most powerful means of subduing the disease; but, as we stated before, the practitioner must consider this treatment as secondary to that which has now been pointed out. There can be no doubt that the establishment of a free salivation is commonly followed by a rapid subsidence of the local disease, but it is also true that the ac- complishment of this is commonly difficult, and often impossible. The more severe the disease, the greater will be the difficulty of inducing ptyfll- ism; and the best mode of insuring the kinoly action of mercury will be to reduce the inflamma- tory condition of the organ as far as possible be- fore its exhibition. We have before stated the remarkable fact that in cases of suppuration of the liver it has been found nearly impossible to induce salivation. It would appear that the safest mode of using mercury in this disease is by the exhibition of large doses of calomel at long intervals of time; as it is stated upon high authority that the remedy is thus much less apt to irritate the bowels, and that a less quantity of mercury, when thus ex- hibited, will sooner affect the system than a greater quantity given in divided doses. Ten grains of calomel, combined with one or two of opium, may be given twice in the day, or a scruple dose at bed-time, as recommended by the East India practitioners. It is stated that the combination of the calomel with some antimonial, such as the antimonial powder or James's powder, assists in LIVER, (DISEASES OF THE) 173 the speed' production of ptyalism. But of one fact we fet I certain, that if after the use of mer- cury for three or four days free ptyalism be not induced, the remedy should be omiited. In the acute stage of the disease the patient must be kept on a strict antiphlogistic regimen. Effervescing draughts may be allowed, and will often be found to be of great benefit when they act on the skin or kidneys. Mild saline purges with emollient injections should be employed; and the patient may drink a solution of cream of tartar or tamarind tea; and if there be much rest- lessness, an anodyne draught or twelve grains of Dover's powder should be exhibited at night. But if, notwithstanding these means, the tume- faction continues, and the fever assumes a remit- tent or hectic type, the formation of abscess is to be dreaded. Under these circumstances we can no longer push the strict antiphlogistic treatment The patient's strength must be supported by fari- naceous and gelatinous foods, and the exhibition of wine in moderation, with vegetable tonics, will be advisable; poulticing must be diligently em- ployed over the region of the liver, and we must endeavour to bring forward the abscess towards the surface as much as possible; when, in the event of a perceptible and fluctuating tumour being formed, it will be advisable to give exit to the matter as speedily as possible. This, how- ever, is an operation of the greatest importance, and must never be undertaken without a full knowledge of the pathological relations of this disease. We have already alluded to the rarity of adhe- sions between the surfaces of the peritoneum in cases of acute hepatic abscess. It is obvious that for the success or safety of the operation the ad- hesions of the peritoneum is a necessary condi- tion ; for in the event of their not existing, the matter will make its way into the peritoneal cavity, defeat the object of the operation, and almost in- evitably destroy life. To obviate these difficulties, Dr. Graves has proposed a mode of proceeding which has been repeatedly acted on with success in the Meath Hospital. It is, without question, a most important addition to the surgery of the abdomen. In the fourth volume of the Dublin Hospital Reports this eminent and scientific phy- sician has published a case of hepatitis, in which, notwithstanding the employment of active mea- sures, evidences of suppuration occurred. There was no distinct pointing of abscess, so that it was judged impracticable to perform any operation which could reach the contained matter. Under these circumstances Dr. Graves, reflecting on the fact that certain deep-seated collections of matter may be induced to point towards a situation in- which the resistance of the integuments and fascia is removed, proposed that an incision should be made over the most prominent part of the tumour, and carried through the abdominal muscles, so as to reach without dividing the peritoneum. This wound was kept open by plugs of lint, and poul- tices were applied over it. In a few days after a fit of sneezing by the patient, puriform matter in great quantity broke through the wound. The discharge continued copiously for a number of days, and the patient recovered perfectly. We have since witnessed two instances where P* this operation proved successful. It would appear that it not only acts on the principle of removing resistance in a particular point, but also by indu- cing adhesions immediately below the wound, in all probability the result of its immediate irrita- tion. In a case where numerous abscesses ex- isted, and in which this operation was performed over the most prominent part, we found on dis- section that the only point of adhesion of the whole peritoneal surface was that immediately below the wound, and corresponding exactly to its extent. Here recent coagulable lymph was ef- fused, so that there can be no doubt that, had the patient lived longer, the contents of this abscess at least would have been evacuated through the external opening. The operation has every thing to recommend it; it is perfectly safe, productive of no distress to the patient, prevents the chance of effusion into the abdomen, and has been proved to be efficacious. In a case of extensive and chronic hepatic ab- scess with great attenuation of the integuments, we proposed the performance of this operation; but it was determined by the attending surgeon to try the operation of a caustic issue in place of that proposed by Dr. Graves. After the separation of the slough, the matter did not show any dispo- sition to escape. A small valvular incision was then made through the ulcer, which gave exit to a few ounces of puriform matter. This operation was immediately followed by excruciating pain in the abdomen and the most violent peritonitis, evi- dently arising from the escape of matter into the : cavity, and proving that in this case the operation of the caustic had failed in producing adhesions. When the abscess makes its way either exter- | nally or into the lungs or digestive tube, the strength of the patient must be carefully supported by light and nutritous diet, wine and tonic medi- cines, according to the circumstances of the case. The mineral acids may also be exhibited in the diflerent tonic infusions, such as gentian, calumbo, or cinchona. Attention must be paid to the bowels; and it seems not impossible but that a gentle and graduated pressure on the organ might accelerate the cure by inducing a closure of the opening after the matter had been evacuated. The opening of the abscess into the serous cavi- ties appears at first sight a necessarily fatal occur- rence ; and we believe that it has been so in every recorded case, with a single exception. In the report of the Meath Hospital before alluded to, a case is recorded in which death from the perito- nitis was apparently prevented by the opiate and stimulating treatment first proposed by Dr. Graves in certain cases of peritonitis. In the case also of double abscess of the liver which we have re- corded in this article, the patient lived for eight days after the rupture of the second abscess into the peritoneum, and it was evident on dissection that the process of cure had commenced, the gelatinous effusion in many places having assumed an appearance of layers, and presenting large blood-vessels in its interior. In the treatment of chronic hepatitis the first great indication is to remove all unnecessary stimulation of the liver or gastro-intestinal surface. Fermented liquors and all kinds of stimulating food must be inhibited, and the diet of the patient 174 MALARIA AND MIASMA.. must consist of the simplest and most bland arti- cles. The bowels are to be diligently but mildly acted on by gentle laxatives combined with mer- curials, such as the hydrargyrum cum creta or the blue pill. In the commencementof the treatment we should apply every third or fourth day a dozen of leeches to the region of the liver, until we re- move as far as possible the pain and tenderness of the organ. When this is effected, we should re- sort to counter-irritation, which must be persevered in for a considerable length of time. The best mode of proceeding is by the repeated applications of blisters over different parts of the organ, and by keeping up an eruption with a mild tartar- emetic ointment. If these means do not succeed, and if there is no contra-indication, it will be ad- visable to affect the system gently with mercury, which may be done either by the exhibition of a small dose of calomel and blue pill combined with Dover's powder, at night, or by mercurial inunc- tions practised over the region of the liver. Where it is thought unadvisable to use mercu- ry, from the constitution of the patient, the nitro- muriatic acid and the nitrous acid have been strongly recommended. It would appear that the best mode of using these remedies, particularly the first, is by the external application, either by sponging the surface, or by the foot-bath. The following is the mode in which this remedy is re- commended to be used by Mr. Annesley. A mix- ture is made of eight ounces of pure water with four ounces of the nitric and four of the muriatic acid, of the strength of the London Pharmacopoeia. Of this solution from two to five ounces are to be mixed with about three gallons of water at the temperature of 96°, in a high and narrow vessel, and the feet kept immersed in it for about half an hour every night before retiring to rest. If the bath does not cause a prickling sensation in the parts, the next is to be increased in strength. Advantage has also been obtained from sponging the trunk with a similar solution every night. The dilute nitrous acid drink has also been strongly recommended in cases of chronic hepatic affections. It possesses the property of producing a slight salivation, but is much slower in its ope- ration than mercury. Taraxacum is a favourite remedy with many practitioners in these cases, but we are sceptical as to its efficacy. After the disease has been subdued, vegetable tonics may be given to restore the digestive powers. The patient should wear warm clothing, and care- fully avoid any error of regimen that may cause a return of the hepatic disease. In some obstinate cases we have known decided benefit from the use of the seton; and it is scarcely necessary to ob- serve, that where the disease has supervened in a warm climate, removal to a more temperate region will be always advisable. William Stokes. LUMBAGO. (See Rheumatism.) LUMBRICI. (Sec Woums.) [LUPUS. (See Noli Tk Tangere.) MAGNETISM, (ANIMAL). (See Somxam- BlLISM.)] MALARIA and MIASMA. The first of these words, and that which is now generally employed to designate a certain effluvium or emanation from marshy ground, we have adopted from the Italian, It is formed from the coalescence of the words mala and aria (bad air.) Miasma is a Greek word Qntaaua, from uiatvu,, inqumo, polluo,) eigni- fying originally contagion or pollution, but now with the occasional adjunct, marshy, not unfre- quently applied to the same effluvium or emails.. tion. We infer the existence of the matter designated by one or other of these terms, as we do that of contagion in cases of disease which do not furnish a material transferable by inoculation, from certain eflects on the animal economy; and we trace its origin to marshes from its having been observed, for a series of ages, that such effects are produced only in the vicinity of marshes, or at least arc more abundant where vegetable matter and water are so situated with respect to each other, that a chemical reaction between them is possible. The observation of centuries having rendered us well acquainted with certain effects of malaria, we now reason conversely; and when we perceive the more familiar of them, particularly intermittent and re- mittent fevers, we infer its existence, and endea- vour to discover its sources, which may not be very manifest. The chemical and physical properties of malaria are unknown to us ; the experiments which have been hitherto performed to illustrate its nature, or even to discover its presence, having furnished very unsatisfactory results. The air collected above the marshes of fort Fuentes was found by Gattoni as pure as that at the summit of Mount Leguone, if not more so ; and M. Deseye obtained in the most confined marshes as on the most ex- posed hills, 78 parts of azote, 21 of oxygen, and one of carbonic acid, from an analysis of the air. It is true that MM. Thenard and Dupuytren found that the carburetted hydrogen gas disengaged from marshes left in the water through which it was passed a peculiar and very putrescible matter; and M. Julia discovered that dew gathered in the neighbourhood of marshes contains, likewise, a matter capable of fermentation; but there is no evidence that these substances are malaria; nor, | were they proved to be so, do we know anything j of their chemical properties but their capacity of | undergoing the putrefactive process. Even the [ very obvious question, whether malaria is always one and the same, or a multiplicity of marsh poi- [ sons exist, is one which the present state of our knowledge does not enable us to answer decidedly. It has been argued that as the existence of such a poison is known only by its effects on the consti- tution, a variety in these effects should be deemed evidence of a difference in the poison. But it jnay be remarked that tho diseases which are re- puted to originate from malaria pass in the same subject into each other,—intennittents, for instance, into remittents, and inversely; and that, of a cer- tain number of individuals residing in or merely visiting the same place at the same time, and con- sequently exposed to the same morbific cause, some are attacked with one form of fever, others with another. And we know that diseases cer- tainly derived from one and the same poison, such as small-pox, exhibit great diversity of character in different persons. These circumstances favour ; the opinion that there are no differences in the MALARIA AND MIASMA. 179 eflects of thi? poison which may not be explained by a difference in the dose, or of the constitution on which it acts, or by the influence of certain agents, such as temperature, which modify its ope- ration. The fafct most in favour of a multiplicity of poisons is the occasional prevalence of one form of malarious disease, yellow fever for example, in the same situation for months, to the exclusion of all others. But as this occurs only under high temperatures, which at once promote the evolution of the poison, and modify the individual habits on which it operates, we would not consider it to fur- nish conclusive evidence, that the poison acting in this case is specifically different from the mal- aria which produces other forms of marsh fever. [Of late, an attempt has been made by Professor Daniell to show, that sulphuretted hydrogen gas is the pestiferous agent: but as the notion has been exploded under the results of observation, it is unnecessary to dwell upon it.] From what we have said on this obscure branch of our subject, it will be tolerably manifest that on the questions of the nature and simplicity or va- riety of malaria we possess no satisfactory infor- mation whatsoever; and that the legitimate objects of our present investigation are its sources, the laws of its propagation, the extrinsic circumstances which modify its influence, its eflects on the ani- mal economy, and the measures to be adopted to guard against these effects. Though marshes, whether salt or fresh, are pro- lific sources of malaria, especially in a certain stage of the drying process under a hot sun, this poison is the product besides of various sorts of soil, to which the term marsh is by no means ap- plicable. In the warmer regions of the earth these collections of low and dense brushwood, or of reeds and grass which are called jungles, are so familiarly known to be productive of malaria, that jungle-fever is as common a name for mal- arious disease in southern latitudes as marsh-fevers in Europe; and in the warmer regions of Asia, Africa, and America, even the larger and more open woods generate the poison under certain cir- cumstances. Grounds which are alternately in- undated and drained for the cultivation of rice, whether in India or Europe, have been found so injurious to the health of the cultivators and the neighbouring inhabitants, that by some govern- ments, that of Russia for example, this species of cultivation has been prohibited. Wet meadow lands, especially in warm climates, and in tem- perate ones during seasons of unusual heat, have been proved to be sources of malaria; at least agues have been observed to prevail in districts in which no assignable cause for them existed but lands of this description. That the half; wet ditches of fortifications may produce malaria was shown by the result of filling up those of Bourg-en-Bresse, by which process those fevers ceased which had previously so affected the in- habitants, that one half of them were incapaci- tated from any occupation for a third of the year. The mud which is left by the drying of extensive ponds or marshes by the summer's heat, though invested at the time with no growing vegetation, but probably containing vegetable and likewise animal recrements, is capable of furnishing this poison. Lakes, especially if situated in flat coun- tries, are indirectly sources of it, not by the moist- ure of their immediate margins only, but likewise by imparting a degree of the same quality to the adjacent country. Considerable portions of Hun- gary and tracts of land in France are rendered insalubrious from this cause. The mud left by the retiring tide in sea-ports and estuaries is pro- ductive of malaria in hot climates, as is evinced by the fevers with which the crews of boats are at- tacked in such situations; and we have seen rea- son to think that in certain seasons they are not perfectly salubrious in our own. The felling of woods, by which process land previously shielded from the sun's rays (and consequently damp) is exposed to their influence, is often followed by the prevalence of malarious disease in the district in which it is performed. Turning up lands which have long laid in pasture for the purpose of culti- vating them is mentioned both by Volney and Rush as productive of malaria and its consequences. In the West Indies this has been found to be a very dangerous operation, Cassans describing it as sometimes producing fevers which resemble an ab- solute plague, the labourers even dying on the spot if they attempt to remain at night on the ground which they have broken up during the day. (Macculloch on Malaria, p. 112.) The decomposition of vegetable matter in other circumstances than in connection with soil has frequently proved a prolific source of malaria. This is often exemplified by the pernicious effects of steeping flax and hemp; and Rush and others mention examples of fevers originating from the decomposition of coffee, potatoes, pepper, and other vegetables. The sickliness of ships from the leakage of sugar in a damp hold, and the oc- currence of a fever which committed fearful ra- vages on the crew of the Priamus frigate from the action of bilge-water on chips and shavings left in the hold from the repairs of the magazine, as men- tioned by Burnett, may be referred to the same class. Neglected sewers and drains have proved under a high temperature to be productive of fever by generating this poison. If the preceding enumeration of circumstances under which the production of malaria takes place be examined, it will be found that vegetable mat- ter and moisture are present in all the examples, and that animal matter is so occasionally. It is a proper subject of inquiry, and one which has given rise to some controversy, which of these elements j are essential to the generation of the poison, and i under what condition those which are essential ' should exist to possess the power of producing it. | With regard to water, it seems ascertained that j its presence is necessary, if not at the surface, cer- tainly below it; but that the quantity in the for- | mer situation should not be large. Many circum- j stances tend to prove that for the production of malaria only a small proportion of water should [ exist in any situation. It is remarked by African j travellers, that in that country the evolution of malaria commences immediately on the falling of rain, and that of this the inhabitants are so con- scious that they then retire to their houses, and endeavour to exclude even the least access of air. As the rains continue and the ground becomes j thoroughly wetted, the sickness abates, to be re- | newed with greater violence on the retiring of the 176 MALARIA AND MIASMA. rains, and the ground becoming dry. In the case of inundations, it is at their subsidence that sick- ness prevails, as was exemplified by the mortality among our troops under such circumstances during the Burmese war. In temperate climates, a marsh, the whole surface of which is thoroughly wet, is comparatively innocuous; but if partially or en- tirely dried by the summer's heat, it becomes ex- tremely pestilential in autumn. Dr. Ferguson, a writer whose extensive opportunities have been aided by great power of observation, has furnished us with many instances, we cannot so justly say, of the small degree of moisture as of the exces- sive dryness which produces malaria in its most intense degree. " The army," says this writer, "advanced on to Talavera through a very dry country, and in the hottest weather fought that celebrated battle, which was followed by a retreat into the plains of Estremadura, along the course of the Guadiana river, at a time when the country was so arid and dry for want of rain, that the Guadiana itself and all the smaller streams had in fact ceased to be streams, and were no more than lines of detached pools in the courses which had formerly been rivers; and there they suffered from remittent fevers of such destructive malignity, that the enemy and all Europe believed that the British army was extirpated. The aggravated case of the disease differed little or nothing from the worst yellow fevers of the West Indies ; and in all the subsequent campaigns of the peninsula, the same results uniformly followed, whenever, during the hot season, any portion of the army was obliged to occupy the arid encampments of the level country, which at all other times were healthy, or at least unproductive of endemic fever."* The writer can vouch from personal observation for the accuracy of this description ; and he has re- peatedly observed that cases of fever and ague abounded in parts of Estremadura so remote from the Guadiana or any stream, that no influence from visible water or dampness could be supposed to have a share in their production. The following example taken from Dr. Fer- guson's paper is strongly illustrative of the same facts, the effects of concealed water in producing the poison. The approach to the town of Ciudad Rodrigo is through a bare, open, hollow country, that has been likened to the dried-up bed of an extensive lake. Upon more than one occasion, when this low land, after having been flooded in the rainy season, had become as dry as a brick ground, with the vegetation utterly burnt up, there arose fevers among our troops, which, for malig- nity of type, could only be matched by those be- fore mentioned on the Guadiana. It will be readily understood, that though the surface of the soil which produces fever may ap- pear dry or even burnt, yet as its occurrence takes place after rains, there is no proof that the pre- sence of moisture is not necessary, but evidence of the very reverse, though it is shown that the dampness need not exist on the surface. The na- ture of the sub-soil, — its being, for instance a dense clay, which by preventing percolation may detain the water within a short distance from the *On the Nature and History of Marsh Poison, by Win. Ferguson, M. D., &c. (from the Transactions of the Royal Society of Edinburgh), Edinburgh, 1821. ground,—has probably some influence in engen- dering sickness ; but there are many facts which prove that an impermeable subsoil is by no means essential to the production of the poison. The lee- ward shore of Guadaloupe, Dr. Ferguson informs us, so far from being impermeable, is a remarka- bly open and pure one, being mostly sand and gravel, altogether without marsh in the mo6t dan- gerous places ; yet it is inconceivably pestiferous throughout the whole tract. The soil of Walche- ren, too, of the pestilential nature of which we have had such melancholy experience, is sandy, or a mixture of clay and sand. These examples tend to confirm, so far as the water is concerned, the law of Dr. Ferguson, that the only condition indispensable to the production of the marsh poison on all surfaces capable of absorption is the paucity of water where it had previously recently abounded; a rule, to which he assures us there is no exception in climates of high temperature. It ought at the same time to be remarked, that though the formation of ma- laria is perfectly compatible, as the writer can tes- tify from personal observation, with the degree of superficial dryness described by Dr. Ferguson, it may likewise consist with a degree of manifest moisture. The necessity of the presence of vegetable mat- ter has hitherto constituted an important part of the creed regarding malaria, but this necessity is questioned in the paper in the Edinburgh Philo- sophical Transactions, to which we have so often adverted. We have already mentioned Dr. Fer- guson's opinion, that the only essential requisite for the formation of the poison is, that water should be absorbed by soil and then exposed to speedy evaporation; and the following example is given of the apparent absence of vegetable mat- ter from a situation abundantly productive of mal- aria. " In Spain, during the month of May 1809, which was cold and wet, the army remained healthy ; but in June, which was remarkably hot and dry, marching through a singularly dry rocky country of considerable elevation, several of the regiments bivouacking in hilly ravines which had lately been water-courses, contrary to the advice of officers who had served in the Mediterranean, several of the men were seized with violent remit- tent fever, (the first that had shown itself in the march,) before they could move from the bivouac the next morning; and this portion of the troops exclusively were affected with this disorder foi some time. In this instance, the half-dried ravine having been the stony bed of a torrent, in which soil never could be, the very existence of vegeta- bles, and consequently of their humid decay and putrefaction, was impossible, and the stagnant pools of water still left among the rocks by the water-course, and near which these men encamped, were perfectly pure. Yet this situation proved as pestiferous as the bed of a fen." Even in this situation, which furnishes the strongest argument that could be adduced for the author's departure f[.oni the established creed, it would perhaps be difficult to prove the total absence of vegetable matter, not only from the surface of the ravines, but beneath the rocky surface; and certainly there exist many facts which prove that vegetable mat- ter is m the highest degree iavourable to the pro- MALARIA A duction of malaria, if not essential to it. These are, the universal presence of such matter where the poison is generated, the cases adduced by Dr. Ferguson and similar ones excepted, if they are to be regarded as exceptions ; the pernicious effects of the steeping of hemp and flax, for we presume it will not be argued that in this case the mere evaporation of the water, independently of the vegetable matter, would produce the poison ; a similar result from the leakage of sugar and the decomposition of coffee, potatoes, pepper, &c, and the fever which committed" such ravages on board the Priamus frigate from the action of the bilge-water on the chips and shavings left in the hold. A similar argument may be deduced from the wholesomeness of peat-bogs, which seem us well calculated as any marsh to produce malaria, excepting that the vegetable matter they contain being in a sub-carbonized state is not susceptible of decomposition. Since there is no reason to think that the evaporation of mere water will pro- duce the poison, we are compelled to conclude that, if there was no vegetable matter present in the cases mentioned by Dr. Ferguson, some in- fluence from mere terrestrial soil gave rise to the effects, which are usually owing to the presence of such matter. The necessity of the putrefaction of the vege- table matter present when malaria is produced, is a different question from that which we have just considered. In by far the greater number of cases in which this poison is generated, there is no offensive smell whatever; it is true that a marsh or other source of malaria may be at once noisome to sense and pestilential, but it is frequently the latter without being the former. Although it has been shown that vegetable decomposition is in- strumental in the production of the poison, if not strictly essential to it, yet the circumstance of its being generated in abundance without there being any perceptible smell, and in situations so dry that vegetable putrefaction, in the ordinary sense of the term, seems impossible, appears to prove that this decomposition is either in degree or kind different from putrefaction, though the two may coexist. Malaria is generated in so many instances in which animal matter does not exist, that we must conclude that the presence of such matter is not essential to the formation of the poison; whether, when present, it increases the quantity or modifies the nature of the miasma, does not appear to be ascertained. [On the evidences in regard to animal or vege- table putrefaction, or both being the cause of mala- ria, the writer has entered at great length in his Human Health, p. 64, Philad. 1844. He regards the affirmative as by no means proved.] Heat is the extrinsic agent most influential in favouring the production of malaria in soils and situations capable of engendering it—an influence attributable probably to the effect of a high tem- perature in favouring the chemical action between organized recrements and humidity, and likewise to its accelerating the formation of the aqueous vapour which appears to be the vehicle of the dif- fusion of the poison. Hence, even the milder forms of malarious disease are observed only in seasons of a certain degree of warmth, rarely, for Vol. III. —23 fD MIASMA. 177 instance, arising in this country before the vernal or after the autumnal equinox ; whilst the more intense degrees occur only in the higher latitudes, or, if seen in climates ordinarily temperate, it is during seasons of unwonted heat; and whereso- ever they exist, their prevalence is terminated by the cold of winter. It has often been observed, that a summer of unusual warmth, especially if occurring after a wet spring, causes intermittent and remittent fevers to reappear in districts whence they had long been banished by the im- provement of agriculture,—an occurrence, of the possibility of which medical men should be aware; for when the malarious disease has made its visi- tation in the form of remittent, it has not always been discriminated from typhus, and confusion and controversies have thence arisen, not very creditable to all parties concerned. The branch of our subject now to be considered, the propagation of the poison, is one regarding which we possess a considerable degree of irre- gular knowledge, consisting rather of detached facts presenting various unexplained anomalies, than of groups of corresponding facts from which the medical reasoner can deduce fixed and deter- minate laws. As might be supposed, the effect of the poison is in general more intense in pro- portion to the proximity to its source. This is probably owing to the more condensed state in which malaria exists near to the spot where it is generated ; and it is remarked, that circumstances which favour its condensation add to the intensity of its effects. It appears to be on this principle that the vicinity of swamps is so much more per- nicious in the evening or night than during the day. The influence of a high temperature in favouring the production of the poison, has already been pointed out; but it appears that during the portion of the day when the temperature is at its highest, the mobility of the atmosphere is so great, and favours so much the diffusion of the poison, that it is comparatively innocuous near the spot where it is generated ; but in the more quiescent state of the air in the evening, though it is less abundantly formed, it is infinitely more pernicious. Its effect at these times is aided pro- bably by its finding a powerful vehicle in the mists, which at night are observed to rest over low and marshy grounds. The more pernicious effect of the night-air in a pestilential country and season, however it is to be explained, is familiarly known, and is often exemplified by the fatality to soldiers of certain night-guards. But to this general law, that malaria is more pernicious in proportion to the proximity to its source, there are important exceptions. In some instances it is found to affect places at some dis- tance, especially if they are situated on an emi- nence, with the same if not greater intensity than those in the vicinity; thus the neighbourhood of Versailles is powerfully influenced by the marshes of St. Cyr; and at Neuville-des-Dames, above Chatillon on the Indre, fevers are more prevalent than close to the marshes where the malaria is produced. The stagnant water, of Lake Aguano. we learn from M. Monfalcon, exhales deleterious effluvia, which are carried backwards to the north- east to two or three villages, and even to the con- vent of Comaldules, a league distant, and situated 178 MALARIA AND MIASMA. on a high mountain. But the most extraordinary instance of this kind is mentioned by Dr. Mac- culloch, as occurring in Malta; the malaria which is produced on the beach beneath a cliff producing no effect on the spot itself, while it affects, even to occasional abandonment, the village situated above. In explanation of circumstances of this nature, of which it were easy to multiply examples, M. Monfalcon supposes that the aqueous vapours in which the marsh poison is dissolved, are raised during the day by the heat and consequent ex- pansion of the air, and are condensed and precipi- tated on the adjacent hills during the evening; whilst Dr. Ferguson conceives that so far from rising into the atmosphere, malaria has a peculiar attraction for the earth's surface, along which it creeps so as to concentrate and collect on the sides of the adjacent hills. We doubt whether either of these explanations is very satisfactory, and think it probable that the explanation of these facts is to he found simply in currents of air which sweep the surface of the marsh, so as to prevent the accumulation of the emanations there, and convey them in a state of condensation to the more elevated. spots situated in the line of the atmospheric movements. The situation of certain elevated places, which have been power- fully influenced by marsh emanations, has fre- quently been observed to correspond with the direction of a manifest current of air which passed over the surface of a swamp. Chains of hills in Corsica and Italy, very far from morasses, but placed in their line, and in the face of a wind which carried to them their emanations, were en- tirely depopulated and rendered uninhabitable. Orlandi cites an analogous example: — the south winds passed over stagnant waters before arriving at some hills, the air of which they infected: these heights became salubrious only when Pope Paul V. had caused the marshes to be drained. The distance to which marshy emanations may extend by gradual diffusion, has been calculated by Monfalcon to be 1,400 or 1,600 English feet of elevation, and from 600 to 1000 in a horizontal direction. In Europe these limits, he supposes, cannot be exceeded; but in equatorial regions the activity of the poison is much more extended; and in the West Indies, vessels at the distance of !?,000 feet from the marshy coast have felt their baneful effects. But when winds are in operation, their influence may extend to much greater dis- tances than those mentioned. The case of the convent of Comaldules, which was infected at the distance of three miles, has already been quoted; but we know not any facts which teach us the ex- treme limits to which the poison may be trans- ported. The distance will probably be influenced if the ground be such as to preserve the poison in a state of condensation instead of allowing it to be diffused; thus, a current of air sweeping up a valley, at the mouth of which the surface is swampy, will convey the poison to a greater dis- tance than it could reach in a more open situation. An instance of this kind occurs in Ceylon, where the poison is conveyed many miles inland up a valley, whenever the sea-breeze blows in such a direction as to cross the swamps on the shore and enter its mouth. We should take but an imperfect view of malaria did we consider intermittent and remittent fevers its sole results. Besides these its more fa. miliar effects, organic affections of the spleen, liver, and mesenteric glands; similar affections of the stomach and intestines ; dropsy, apoplexy, palsy, and idiocy, as manifested in the marshy districts of Tuscany, and in the cretinism of the valleys of Switzerland, are the effects of its long. continued application. Cholera, dysentery, and diarrhoea, are by many writers referred to its more brief agency, and there is reason to think occa- sionally with justice; intermittent neuralgia, there seems little doubt, is one of its effects, and to this formidable list some are disposed to add rheuma- tism, but the propriety of this seems doubtful. It is observed that the natives of marshy districts, who permanently reside in them, lose their whole bodily and mental constitution, contaminated by the poison they inhale. Their aspect is sallow and prematurely senile, so that children are often wrinkled, their muscles flaccid, the hair lank, and frequently pale, the abdomen tumid, the stature stunted, and the intellectual and moral character low and degraded. They rarely attain what in more wholesome regions would be considered old age. In the marshy districts of certain countries, for example Egypt, Georgia, and Virginia, the ex- treme term of life is stated to be forty ; whilst we learn from Dr. Jackson, that at Petersburg, in the latter country, a native and permanent inhabitant rarely reaches the age of twenty-eight. [Dr. Jackson's remark must have been made, however, on inadequate statistical evidence, and probably on no statistical evidence whatever. If it were ever correct, it is utterly inapplicable to the Petersburg of the present day.] In the portions of Brittany which adjoin the Loire, the extreme duration of life is fifty, at which age the inhabitant wears the aspect of one of eighty in a healthier district. It is remarked that the inferior animals and even vegetables partake of the general depravation; they are stunted and short-lived. By the progress of civilization, and conse- quently of agriculture, the domain of malaria is diminishing throughout the more enlightened por- tions of the earth. This is manifest in our own country, from many parts of which, where they formerly prevailed, agues have been banished, The draining of swampy lands; preventing in ponds or other damp situations the accumulation of putrid or putrescible vegetable or animal mat- ter ; and, in marshes situated near the sea, pre- venting by embankments the mixture of salt water with fresh, from which combination most pesti- lential emanations have always been observed to proceed, are the most efficient means of reclaiming malarious tracts, and consequently of preventing the production of the poison. But some lands are of so incorrigible a nature, the Pontine marshes for example, that the hand of man has hitherto been employed upon them in vain; and it is desirable to know, since we cannot prevent such districts from generating the poison, how its diffusion and pernicious influence maybe in some degree checked. It is remarked that malaria has a peculiar attraction for certain surfaces, and that it is not disengaged from those to which it adheres, at least not in a noxious form ; in other words, MEDICINE, (HISTORY OF) 179 they do not constitute fomites. The attraction of the poison for trees is great; and it has repeatedly been observed that not merely a few individuals, but the population of whole cities, situated in the rnut swampy districts in the world, have owed tlu-ir security to a screen of woods interposed be- tween them and the marshes. Facts of this nature suggest very obviously the propriety of planting trees in the vicinity of irreclaimable swamps. The floors of dwellings are supposed to have a similar attractive power over the poison; and hence, in malarious districts, the second stories of houses are found to be more salubrious than the first; and if from circumstances the first floor must be occupied, some security is afforded by having the bed a few feet elevated from it. Nutritious diet, and that kind of general regi- men which is most conducive to good health, should be observed by individuals exposed to the operation of malaria ; and they should be especi- ally careful to avoid, if possible, the vicinity of swamps in the evening. JosEpH Brqwn# [MANIA. (See Insanity.) MEASLES. (See Rubeola.)] MEDICINE, (HISTORY OF*) — CHAP- TER I.—Introduction—Division of the his- tory of medicine into three great chronological periods—History of medicine previously to its introduction into Greece—Origin of medi- cine — State of medicine among the Egypt- ians — Among the Assyrians — Among the Jews—Introduction of medicine into Greece— Chiron — Aesculapius — Machaon — Podali- rius—The Asclepiades—Records in the temples of Aesculapius — Ancient inscriptions — Py- tfiagoras—Democritus—Heraclitus—Acron — Hcrodicus—Gymnastic medicine. Although the primary object of this treatise is to present a view of the history and progress of practical medicine, yet it will be impossible to avoid entering occasionally into the consideration of the various theories and speculations which have so generally prevailed in the science. Medi- cal theory and practice have been so intimately blended together, that it would be useless to at- tempt to separate them. The terms which are employed, in works of the most practical nature, are, for the most part, derived from the theory which was current at the time of their publica- tion, and even the narrative of facts and the direct details of experience are, with a few exceptions, deeply tinged with the prevailing doctrines of the day, or with the individual speculations of the writer. Those who are versed in medical science, and who are acquainted with the relation which it bears to the other physical sciences, with the mode in which it is acquired, and the nature of the evidence on which it rests, will easily perceive * The writer of this Essay begs to remark that the references inserted at the root of the page are to be regarded as the authorities for the facts and dates con- tained in the text; with respect to the opinions that are maintained, he is to be considered as alone answerable lor them. Where he has conceived it necessary to dis- sent from, or to controvert, the doctrines of his predeces- sors, he has endeavoured to do it without acrimony or arrogance, and he trusts that his remarks will be received with the same spirit of candour in which they are offered. He thinks it necessary to state that wherever a reference is made to any book, the book so referred to has been examined by him. that, in this department, it is peculiarly difficult to separate facts from hypothesis. It may, however, be asserted, that until this be accomplished, medi- cine can never be placed upon the basis of induc- tion, and that this alone can give it that stability, which may entitle it to be regarded as a correct science. In its present condition it will be impos- sible to do more than to approximate to so desira- ble a state, but it will be a special object of atten- tion, in the following pages, to endeavour to point out the limits between practice and theory, between facts, and the opinions that have been deduced from them. When we take an extended view of the pro- gress of medicine, tracing it from its scanty sources, in the most remote periods of society, and observe its course, as gradually augmented by the stores of Grecian and Roman learning, obscured by the darkness of the middle ages, and again bursting forth in the copious and almost over- whelming streams of modern literature, we are naturally led to separate the narrative into three di- visions, corresponding to the three great chronologi- cal periods. The first of these will comprehend the history of practical medicine, from the earliest re- cords which we possess, to the decline of Roman literature; the second will contain an account of the state of the science, through what are termed the dark ages, until the revival of letters ; the third will commence with the establishment of the inductive philosophy, and be continued to the present time. In tracing the history of this science from its earliest records, it will not be necessary to devote much time to a subject, which was formerly dis- cussed with great learning and acuteness, viz. the origin of medicine. It may be sufficient to re- mark that, in proportion to the progress of civili- zation or refinement, attempts would be made to remove or alleviate the diseases, and to repair the injuries, to which the body is constantly incident. Subject as it is, at all times, to the influence of various noxious agents, and to a consequent de- rangement of its functions, to painful affections of various kinds, and to the loss or depravation of its powers or actions, we must conceive that man- kind would be anxious to remove or relieve these evils. The means that would be employed must have been, in the first instance, extremely imper- fect, and frequently ill directed. They may have been suggested by the effects of certain kinds of food, or by the operation of certain external agents on the body : some analogies may have been derived from the spontaneous actions of the system, by observing the natural efforts of the constitution to remove certain causes of disease, or to relieve the patient when suffering from their effects. Thus, in the earliest periods of society, mankind must have been aware of the relief which was obtained, in the derangements of the alimentary canal, by an evacuation of its contents, and would probably have discovered, incidentally, that certain vegetable substances promoted this operation. In the external injuries to which the body is subject, more especially in a rude state of society, means would early be had recourse to for procuring present ease from pain, or for removing the obvious danger to life, which would so fre- quently follow from various causes. It would soon be found that the pain was diminished by 180 excluding the wounded part from the air, or from other extraneous substances; that by certain modes of pressure, the flow of blood might be restricted ; and that, in some cases an increased, and in others a diminished temperature, gave immediate ease to the patient, and tended to promote the ultimate cure. A rude species of medical and surgical practice of this description has been, in all cases, found to exist in newly-discovered countries, even when in the most barbarous state; while it has been observed generally, that the improvement in the healing art has been nearly in proportion to the advancement of the other arts of life, and to the gradual progress of knowledge on all subjects intimately connected with our existence or wel- fare. The historical records which we possess respect- ing the progress of practical medicine are scanty and uncertain; but, so far as they extend, they coincide with the view of the subject taken above. The writers who have investigated this point with the greatest learning and assiduity inform us, that Egypt was the country in which the art of medi- cine, as well as the other arts of civilized life, was first cultivated with any degree of success, and that it had advanced so far as to have become a distinct profession. We are not, however, in- formed in what degree or to what extent that dis- tinct appropriation was carried; whether medicine was made the exclusive business of certain indi- viduals, who were regularly instructed for that purpose; whether it was attached to certain pub- lic functionaries, especially to the priests; or whether persons in different situations applied themselves to the practice of medicine, from a real or supposed superiority in their skill and in their knowledge of the treatment of diseases. The probability, however, is that the priests of the Egyptians were at the same time their physicians. This appears to have been the case among the Jews and the Greeks, who are supposed to have borrowed from the Egyptians many of their insti- tutions ; and indeed it seems to be the natural progress of society in its earlier periods, when the priests were generally the depositaries of know- ledge of all kinds, and when they confined it as much as possible to their own use, for the purpose of maintaining their influence over the rest of the community. From some remarks which are made incident- ally in the Mosaic writings respecting the learning of the Egyptian priests, it would appear that it con- sisted, in a great measure, of the employment of magical incantations, and, so far therefore as it effected the cure of disease, must have operated through the medium of the. imagination. This has been, in all cases, the first step in the art of medicine, if it may be so called, and its efficacy must have been in exact proportion to the igno- rance and superstition of the people on whom it was exercised. A circumstance respecting the practice of medi- cine in Egypt is mentioned by Herodotus, as ex- isting when he visited that country, and which it may be presumed, was transmitted from "a much earlier period, that certain individuals treated cer- tain diseases only. (Euterpe, sec. 84.) This division into separate branches might, at first view, seem to indicate a considerable progress in MEDICINE, (HISTORY OF) the practice of medicine, and it may undoubtedly have led to a degree of manual dexterity and of minute observation in certain departments. But, independent of any other consideration, we may rest assured, that the science must have remained in a state of complete degradation, when we bear in mind that it was the custom in Egypt, as it is in the present day among many of the nations of the east, to transmit the same occupation from father to son, through a number of successive generations. This practice, although it maybe favourable to the perfection of an art, or even of a science, in some of its minute details, must fur- nish an almost insurmountable obstacle to its general improvement, or to the development of the powers and faculties of the human mind. Although we are in the habit of considering Egypt as the parent of the arts and sciences, the empire of Assyria has been supposed, by many learned men, to possess a greater claim to this distinction. Perhaps the priority of invention may be justly awarded to the Assyrians, but the memorials which they have left behind them are so scanty, that the degree of excellence to which they arrived is almost entirely conjectural. The priests of this nation, as in all other cases, appear to have been the depositaries of all the learning of the times, and of that of medicine among the rest. We have reason to suppose that their prac- tice consisted of little more than the dexterous application of magical arts, and such other means as tended to impress the minds of the people with a sense of their power over the operations of nature, while any actual information which they possessed was carefully concealed under the guise of mystery and superstition. (Herodotus, Clio, passim; Enfield's Hist, of Phil. v. 1. p. 25 et seq.) In the writings of Moses there are various al- lusions to the practice of medicine among the Jews, and more especially with regard to the treatment of leprosy. 1*he priests appear in this, as in other cases, to have been the practitioners; the treatment consisted principally in certain re- gulations for the purpose of promoting cleanli- ness and preventing contagion, together with various ceremonies, which, so far as they could affect the patient, must have acted entirely on the imagination. (Leviticus, chap, xiii.-xv.) So lit- tle is known respecting the state of the arts and sciences in the other countries of the east, at these remote periods, that it is scarcely necessary to allude to them in this place. We shall only re- mark that the imperfect and scanty notices which we possess on this subject would lead us to con- clude, that the practice of medicine was even in a less advanced state than among the Egyptians, its progress being regulated by the greater or less degree of refinement or civilization of the respec- tive countries, but in no case having advanced beyond the state of implicit credulity and gross superstition.* * For further information respecting the state of medi- cine anion? the Egyptians and the other nations of anti- quity, previously to the Greeks and Romans, the reader is referred to the following works. Herodotus, Euterpe et Clio, passim. Diodorus Siculus, lib. i. sect. 25. 8- Plinius, lib. vii. cap. 56, lib. xxix. cap. 1. Plutarchus, De Iside et Osiride. Josephus, Antiq. Jud. lib. vni. cap 2, sec. 5. Clemens Jllciandrinus, a Potter, Stromat. Ill) vi. p. 7o8. Conring. Introd. Art. Med. cap. 3, sit. 2, et We Hermet. Wed. passim. Burchusen, Diss No. 1, et 7 MEDICINE, (HISTORY OF) 181 After having given an account of the state of I medicine among the ancient Egyptians and other contemporary nations, as far as can be gleaned from the scanty records that remain on this sub- ject, we must follow it into Greece, and trace its progress from the period of its first introduction in the remote and semi-fabulous ages of their demigods and heroes, until it acquired the rank of a science under the genius of Hippocrates. It is generally admitted, that although Greece cultivated the arts and sciences with so much success, yet, in the first instance, she borrowed them from the neighbouring nations; principally, as it would appear, from Egypt, and in some cases from Phoenicia. (Vide Bryant, ubi supra, et v. 2, p. 426 et seq. et alibi.) To certain individuals who migrated from these countries, the Greeks them- selves were in the habit of referring the introduc- tion of many of the most useful inventions, and during a considerable space of time all those who were desirous of acquiring a larger share of know- ledge, either theoretical or practical, than was possessed by their countrymen, visited Egypt, as the great storehouse of science and learning. It is from this cause that we find so much analogy between the divinities that were worshipped in the two countries, as inventors or patrons of the various arts and sciences. For although they acquired new names on their being transferred into Europe, yet their attributes, and even their forms, clearly demonstrate their origin. This is particularly the case with respect to medicine, so that in the Orus and Thouth of the Egyptians we may recognise the prototypes of the Apollo and Hermes of the Greeks. (Haller, Bibl. Med. Pract. lib. 1, sec. 7, 8. Hundertmark, in Acker- mann, Opuscula, Exerc. No. 1.) It is not until comparatively at a late period, approaching to that of the Trojan war, that we find the names of actual personages who practised medicine in Greece ; and of these, it is probable that some were natives of either Africa or Asia, who brought with them the information which they had acquired in their respective countries. Of those whose history is better known, and who were acknowledged to be of Grecian origin, it was the general custom to travel into Egypt for the purpose of obtaining a knowledge of their art, and with this view they submitted to a sys- tem of rigid discipline, and to a variety of irksome and burdensome ceremonies; and after all this laborious process, so far as the science of medicine is concerned, the result seems to have been little more than the knowledge of magic and incanta- tions, with some rude notions respecting the ap- plication of external remedies} for the cure of wounds and of cutaneous diseases, with a very imperfect idea of the anatomy of the human body, and a very inadequate conception of its functions. (Herodotus, Euterpe, passim. Diodorus Siculus, lib. 1. passim. Josephus, Antiq. Jud. lib. viii. cap. Orvncr, Analecta, Diss. 1. De ^Egyptiorum Veterum Anatome. Schu/z, Hist. Med. p. 1, sec. 1 Clcrc, Hist, de la Med. par. 1, liv. i. chap. 1-8. Sprengel. Hist, de la Mr;l. par Jourdan, sect. 2, ch. 1—3. Knfield's Hist, of I'hil. v. 1, p. 80, 7, et alibi. Pauw, on the Egyptians and Chinese, part J, sect. 2. Bryant's Analysis, v. 2, p. 324 et seq. et in multis aliis locis. Cabanis, Revol de la Med. ch. 2, sect. 1. jjckermann. Insist. Hist. Med. p. 1, c. 1,2. Lauth, Hist, de I'Anatoinie, liv. i. Blumenbach, Introd. in Historiam Medicinte Litter, sect. 1—3. 2, sec. 5. Odyss. xix. 656 et seq. ^Eneis, vii. 753 et seq.) The first native of Greece who is more particu- larly singled out, as having introduced the art of medicine among his countrymen, is the centaur Chiron. There is much mystery attached to his character and to every thing connected with him, but what we may consider as the most probable conclusion is, that he was a prince of Thessaly, who lived about the thirteenth century before the Christian sera; that he was distinguished above his contemporaries for his knowledge of the arts of life, and that, after the manner of his country- men, he was frequently seen on horseback, so as to give rise to the fabulous account of his com- pound form. He is particularly celebrated for his skill in medicine and in music, a combination, it may be remarked, that was said to have existed in many other individuals. We are not informed by what means he obtained his superior know- ledge in medicine, but there are various circum- stances, which lead us to conclude, that it was at that time regarded rather as a part of the educa- tion of all men of rank, than as attached to a particular profession. We accordingly find that he instructed the Argonauts in medicine, and the heroes who were engaged in the siege of Troy, and that all the kings and warriors of that period were more or less acquainted with the treatment of wounds, and even with the practices which were adopted for the cure of internal diseases. (Ilias, xi. 636 et seq. Sprengel, t. 1, p. 112, 13. Ackermann, per. 1, cap. 3, sec. 25—40.) But although Chiron has the reputation of having introduced the art of medicine into Greece, it is to his pupil ^Esculapius, that by the common consent of antiquity, is ascribed the merit of having first devoted himself to the cultivation of medicine as a science, and of having made it a distinct object of pursuit. The improvements which he made in the art were so considerable, as to have induced his countrymen, after his death, to pay him divine honours, to designate him as the god of physic, to erect temples to him in va- rious parts of Greece,* and to derive his origin from Apollo himself. His history, when divested of all the fabulous appendages that were attached to it by his contemporaries, appears to be that he was a native of Epidaurus, that he was exposed in his infancy, probably in consequence of his illegitimate birth, that he was accidentally disco- vered by a shepherd, and placed under the care of Chiron. His death was said to have been caused by the jealousy of Pluto, in consequence of the number of individuals whom he rescued from the grave; from which tale we may at least conclude that his reputation as a successful prac- titioner must have been much higher than that of any of his contemporaries.-)- According to the custom of that age, he trans- * Pausanias, lib. i. cap. 21; ii. 10; ii. 13; iii. 22; iv. 31 ; vii. 21 ; vii. 23; vii. 27; viii. 25. Strabo, lib. viii. p. 592; ix. ttfrt; xhi. 8119; xvi. 10:>7, a Casaubon, Amst. 1707. Clerc, pnrt 1, liv. i. ch. 20. t Diodorus Siculus, lib. iv. sec 71. Hyginus, fab. 49 et alibi. Clerc, part i. liv. i. ch. 11—10. Ortelius, Capita Deor. lib. ii. in Gronovii Thes.Graec. t 7. p. 278 et seq. Montfaucon, Antiq. v. i. book ii. chap. 1, 2. Sprengel, t. i. p. HUetseq. rfckermann, per. 1, cap. 3, sec. 41—59; and especially the second dissertation in his Opuscula, by Giinzius and Richter. 192 MEDICINE, (HISTORY OF) mitted his profession to his sons Machaod and Podalirius, who accompanied the Greeks in the Trojan expedition, and are celebrated in various passages of the Iliad for their medical skill.* From the incidental mention that is made by Homer and the early Greek writers of the nature of the reme- dies that were employed by these individuals or their contemporaries, it will appear that their prac- tice was principally surgical, and nearly confined to the treatment of wounds, and that, with respect to internal diseases, they were for the most part conceived to be the immediate infliction of the Deity, and were therefore abandoned as incurable, or at least were to be obviated only by charms and incantations, and that the arts of magic formed no inconsiderable part even of their surgical practice. (Ilias xi. 636 et seq. Odyss. xix. 456 et seq.) The practice of medicine remained for a con- siderable time hereditary in the family of JSscu- lapius, and in a great measure confined to it. His descendants obtained the name of Asclepiades; they were the priests of his temples, and presided over and directed the rites and ceremonies.— (Sprengel, t. i. p. 168 et seq.) These temples, indeed, became a species of hospitals, to which patients resorted from all quarters for the relief of the diseases with which they were affected. Under the direction of the priests of these temples they underwent a variety of ceremonies, the immediate effect of which must have been principally upon the imagination. Some, however, of the prac- tices which were enjoined were of a dietetic na- ture, and were directly conducive to temperance and cleanliness; such as frequent ablution, and the abstaining from certain kinds of food. To these if we add that the temples were generally erected in healthy situations, that the patients en- joyed rest and leisure, and that the mind was in- terested by a succession of new and pleasing im- pressions, we may suppose that they would be placed under circumstances, not a little resembling those which are found so conducive to health by the invalids who frequent the medicinal springs and other analogous establishments of modern times. (Clerc, part i. liv. ii. ch. 2-6. Sckulz, par. i. sect. 2, cap. 4. Sprengel, t. i. p. 153 et seq. Cabanis, p. 59, 60.) Although the accounts that have been transmit- ted to us respecting jEsculapius would lead us to conclude that he was a real personage, who actu- ally possessed a greater degree of medical skill than any of his contemporaries, yet his whole history is so involved in fable and mystery, that it is impossible to obtain any correct idea of the de- tails of his practice. It has been observed above that it was probably, in a great measure, surgical, and even confined almost exclusively to the cure of wounds or recent injuries. The treatment of these may be considered so far judicious as it was simple; it consisted in removing all extraneous bodies, in placing the parts as much as possible in their natural position, in fomentations and ablu- tions, and in the application of certain vegetables which were supposed to be possessed of balsamic or styptic properties. Wine and other articles of * Clerc, part 1, liv. i. chap. 17. Sprengel, t. i. p. 127 et seq. Ooulin, " Anciens Medecins," in Encyc. Method. " Medecine ;" this article may be advantageously con- sulted on the subject of the Greek and Roman "physi- cians. a more stimulating nature were also used, while oleaginous substances were employed nearly with the same intention as in modern times, to defend the part from the air or other external agents, to- gether with bandages and other means of mechani- cal support. We have no distinct evidence how far internal remedies were administered ; for the most part they relied on magical arts and incan- tations, and although we have reason to believe that certain vegetable products were occasionally employed as internal remedies, we are scarcely able to discover what was the object of the prac- titioner, and we are frequently unable to ascertain what were the plants that were employed. (Cel- sus, lib. i. prsef. Plinius, lib. xxix. cap. 1. Clerc, part 1, liv. i. ch. 15. Schulz, p. i. sect. 2, cap. 4. Sprengel, sect. 2, ch. 4, 5. Cabanis, ch. 2, § 1.) But scanty and imperfect as is our knowledge of the state of medicine in the age of ^Esculapius, after his death and that of his sons Machaon and Podalirius, we have a long period, extending even to several centuries, during which we have still less information respecting the history and progress of the science. We have not a single improve- ment of any importance recorded as having taken place during this long interval, nor have we the names of any individuals transmitted to us, who were of sufficient eminence to be distinguished above their contemporaries. We learn that the practice of medicine was entirely confined to the Asclepiades, who were the guardians or superin- tendents of the temples that were erected in honour of ^Esculapius. It may be inferred from the very scanty materials which we possess on the subject, consisting entirely of allusions or indirect accounts, scattered through the works of the older poets and historians, that they sedulously kept up the system of rites and ceremonies, which had been handed down to them from still more ancient practitioners, that they carefully preserved to them- selves the sole management of the art over which they presided, and we cannot doubt made use of the influence which they acquired over the minds of their contemporaries for the purposes both of gain and of ambition.-J- But although we regard the general system of the priests of ^Esculapius to be nothing more than a tissue of mystery and de- lusion, it is very probable that the ample opportu- nities which they possessed of witnessing the phenomena of disease in all its forms might enable them to obtain much valuable information respect- ing the nature and tendency of the morbid actions of the body, and of the effects of certain agents upon them. Men possessed of superior talents and sagacity would naturally profit by these advantages, and we accordingly find that some of these tem- ples acquired a high degree of celebrity, in conse- quence of the supposed skill of the priests that were attached to them. These opportunities of acquiring experience were much facilitated by a practice, which generally prevailed among the pa- tients, whenever they were cured of their diseases, of depositing in the temple a votive tablet, on which was inscribed a narrative of the case, in- cluding a statement of the symptoms of the dis- t Lucian, in his " Philopseudes," gives an account of various medical superstitions which prevailed at a later period, many of which were probably transmitted from ^he empir.es of antiquity. See Tooke'a Trans, v. i. P MEDICINE, (HISTORY OF) 183 ease, and the means adopted for its removal. The temples were thus converted, to a certain extent, into schools of medicine, and as these records were religiously preserved, they became the repositories of much valuable information, which must have gradually led to an improvement in the art. Of the numerous temples that were dedicated to JEsculapius, there were three which acquired pe- culiar celebrity, those of Cos, of Gnidos, and of Rhodes ; we are informed that Hippocrates made great use of these records, and it has even been supposed that one of the treatises which is generally ascribed to him, « Coacae Pramotiones," was composed from the records which he procured from the temple of Cos. Some ancient inscriptions have been discovered by the researches of the learned antiquaries of the last century, which would appear to consist of memorials of this kind; and from these specimens we may form some idea of the nature of the in- formation that would be conveyed by them. For the most part they state little more than the name of the disease, together with a very brief account of the means adopted for its relief, which in many cases depended entirely upon certain ceremonies, and in others upon the application of remedies which, we may venture to assert, could have no physical operation. (Gruter, Corp. Inscrip. a Gravio, pi. 17 et alibi. Ackermann, Opuscula, Diss. 3. sect. 3, by Hundertmark and Carpzov.) Still, however, some experience of the nature and treatment of disease might have been conveyed by their means, and of this we may presume that an individual of a sagacious mind would have availed himself for the improvement of his art. Among the few circumstances that are trans- mitted to us respecting the principles and practice of the Asclepiades, we are informed that the priests connected with the two rival establishments of Cos and Gnidos devoted their attention in some measure to different objects ; those of the former assumed more of a philosophical cast, attempting to unite reasoning with experience, while the latter attached themselves solely to the observation and collection of mere matters of fact. Hence it would appear that a foundation was thus early laid for the two great sects of the Dogmatists and the Empirics, which long divided the medical world, and the influence of which is, even at this day, not altogether destroyed. We may remark, how- ever, that the philosophy of the school of Cos, if it may be so called, was founded upon such totally incorrect principles, and upon so fallacious a basis, that little immediate benefit was derived from it, and that it was only useful so far as it might lead them to exercise their intellectual powers, and enable them to reason more correctly on medical subjects. By the mode in which Hippocrates speaks of certain practices, such as bleeding and the administration of emetics, purgatives and other analogous medicinal agents, we may infer that they were in common use among his contempora- ries, and probably had been so for a long time before him. We may in some instances obtain a know- ledge of the vegetable substances that were employed in these early ages, as well as of the individuals who introduced them into practice, by the names which were afterwards imposed upon them by the ancients. It must indeed be obvious that the indi-1 cation derived from these names is far from being decisive as applied to any particular case, but we derive a general inference from it as to the nature of the articles employed, while they serve to point out the persons who were supposed to have been the most eminent for their skill or their science. Some centuries had elapsed, during which the practice of medicine continued altogether in the hands of the priesthood, and under their control had remained nearly stationary. It had been exercised, for the most part, for the purpose either of direct emolument, or for the still more selfish purpose of maintaining their influence over the minds of the people, when it began to be cultivated by a different description of persons, much more likely to produce a spirit of improve- ment, and from whom in reality it derived its first impulse. It was during the sixth century before the Christian sera that the genuine principles of philosophy first made their appearance in Greece, and among the other topics which then became the subject of investigation, the powers and func- tions of the human body were examined with considerable attention. This led to an inquiry into the nature and cause of diseases, and to the means of their removal; and although a lonp: period elapsed before much actual advance was made in the knowledge of pathology or of the practice of medicine, yet we observe the effect of a more correct mode of reasoning, and may per- ceive that the strong-holds of mystery and super- stition, although not destroyed, were at least in some degree weakened. (Sprengel, sect. 3, ch. 1.) The celebrated name of Pythagoras may be mentioned as the first of this class respecting whom we have any accurate information, and even his history is enveloped in much obscurity. We may, however, conclude with certainty that he devoted the greatest portion of a long life to the pursuit of natural knowledge, that he made many considerable advances in various depart- ments of science, and among others in the know- ledge of the structure and actions of the human frame. It has been supposed that he dissected the bodies of animals, and hence acquired a certain acquaintance with anatomy, and that he publicly taught what he knew on this subject to a large assembly of students, who came from all the civi- lized parts of Greece and Italy to Crotona, where he established his school. We are informed that, for the purpose of acquiring knowledge, he tra- velled into those countries which, previously to his time, were regarded as the depositaries of knowledge, particularly Egypt, where he is said to have passed no less than twenty-two years, and probably also Chaldsea and some parts of Eastern Asia. From what has been stated above, we may form some conception of the nature of the know- ledge that he would obtain from these sources, and we may conclude that he must have been pos- sessed of a very superior mind to have been capa- ble of extricating himself from the trammels of superstition and bigotry in which every thing con- nected with those countries was involved.* * Diogenes Laertius, lib. viii. cap. 1-50. Cicero, de Fin. v. 29. Faler. Maximvs, viii. 7. JE/ianus, Hist. Var. iv. 17. Clemens Jilexandrinw, Stromat. lib. i. p. 354-7. Faoricius, Bibl. Grac. lib. ii. cap. 12. Enfield, vol. i. p. 422 et seq. Jlckermann, Iiistit. Per. 2, cap. 4, 5 : Opuscula, diss. 4, a Kuhn. 184 We are scarcely able to determine in what degree he directly improved the practice of medi- cine; it is probable, however, that, as he did not make it his profession, but studied it only in con- nection with the other branches of natural philoso- phy, the actual additions which he made to it were not considerable. (Sprengel, t. i. p. 337 et seq.) This we may also conclude to have been the case with many of his pupils, who were among the most justly celebrated philosophers of that and the succeeding age. They may all of them be regarded as belonging to the school of Pythagoras, inasmuch as they cultivated natural knowledge by means of observation, and even occasionally of a rude kind of experiment; and although none of them were exclusively devoted to the study of medicine, yet they gradually and indirectly contributed to its advancement, so as to prepare the way for one of those great and com- manding geniuses who occasionally make their appearance, and by their intellectual ascendency produce such important revolutions in the world of science : it is unnecessary to state that we here allude to Hippocrates. During the interval from Pythagoras to Hippo- crates there are few names that require any par- ticular notice as improvers of medicine. Demo- critus (Clerc, p. 96-101. Enfield, vol. i. p. 422 et seq. Barchusen, diss. No. 1. Sprengel, t. i. p. 261-6) and Heraclitus (Clerc, p. 95, 6. Spren- gel, t. p. 266-9. Enfield, vol. i. p. 436 et seq.) were among the most illustrious followers of Py- thagoras, but they became famous rather from the ingenuity with which they supported their peculiar hypotheses than from the additions which they made to actual knowledge. They applied respec- tively their favourite doctrine of atoms and ele- ments to explain the phenomena of disease, and even the operation of remedies; but, it is unne- cessary to say, with little real advantage. The former of these philosophers, however, deserves honourable mention from the attention which he paid to the study of comparative anatomy ; and it has been conjectured that he so far rose superior to the prejudices of his age as to venture upon the dissection of the human subject. The name of Acron is mentioned by Pliny (Lib. xxix. cap. 1) as among the first who at- tempted, upon any general principles, to apply philosophical reasoning to the science of medicine, but we have scarcely any knowledge of his history or character, nor have we any memorials left of the principles which he adopted. (Clerc, part. i. liv. ii. ch. 7.) We may also select the name of Herodicus as having been considered the inventor of what was styled gymnastic medicine, (Clerc, part. i. liv. ii. ch. 8. Mercurialis, De Arte Gym- nastica. Schulz, p. 192 et seq. Barbier, in Diet. Scien. Med., art. "Gymnastique." Ackermann, per. 2, cap. 6,) which was regarded by the Greeks as a very important branch of the art. Schools for the practice of the gymnastic exercises were established in various parts of Greece, and were placed under the direction and superintendence of persons especially trained for the purpose, who took charge of the health of their pupils, and who appear to have undertaken the treatment both of the accidents which occasionally occurred in their establishments, and also, when necessary, of in- MEDICINE, (HISTORY OF) These gymnasiarchs ternal diseases. These gymnasiarcns, as they were styled, must in this way have acquired a certain degree of information respecting the nature of disease, and seem to have been considered as among the most skilful practitioners of the age in which they lived.* CHAPTER II. — An account of the opinions and practice of Hippocrates and his contempo- raries—Remarks on the history and education of Hippocrates—High estimation in which he was held—Remarks on his character and ac- quirements—On his works — Account of hh principles and doctrines, his physiology, pa- thology, anatomy, and practice. We now enter upon the history of an individual of very distinguished character and acquirements, who was destined to effect a complete revolution in his profession, and to introduce a system which may be considered as having laid a foundation for all its future improvements. The contemporaries and immediate successors of Hippocrates were so sen- sible of his merit that he acquired from them the title, which he has since retained, of Father of Medicine; and it may be confidently affirmed that the science is more indebted to his genius and ability than to that of any single individual. It is a little remarkable that, notwithstanding the great celebrity which he attained, we have no very correct knowledge of his history, of the mode of his education, or of .the means by which he ac- quired his wonderful pre-eminence. All that we are able to learn on these points with any degree of certainty is, that he was brought up amonrr the Asclepiades, who were attached to the temple of Cos, that he studied medicine under Herodicus, and that he embraced the philosophical hypothesis of Heraclitus; he is also reputed to have been a lineal descendant, in the eighteenth degree, from ^Esculapius, and may therefore be supposed to have been devoted to the profession from an early period of life, and must have had access to all the records which were accumulated in the establish- ment to which he belonged. These circumstances may have had the effect of originally directing his mind to the pursuits in which he afterwards became so eminent; but we must suppose that he possessed from nature a genius singularly adapted to the advancement of medical science, by which he was enabled so far to surpass all those who were placed in situations equally advantageous. We are informed that he spent a considerable portion of his life in travelling through foreign countries, partly for the purpose of obtaining information, and partly from the circumstances of his assistance being required to undertake the cure of persons of rank, to arrest the progress of epidemics, or to check the ravages of endemic diseases. The works that he left behind him are very numerous, and considering their antiquity they may be regarded as in a tolerably perfect state. Unfortunately, however, to those which appear to have a just claim to be considered as his genu- ine productions, there are appended a number of * Plato, De Repuh. passim et De Leg. lib. vii. Sc'hull has judiciously summed up in a Kt-ries of general propo- sitions the history and progress of medicine up to the period at which we are now arrived ; p. 201 2. MEDICINE, (HISTORY OF) 185 others, which it may be concluded are spurious, either written by his pupils or successors, or fraudently attached to his name in consequence of its great celebrity. Many eminent critics have exercised their ingenuity in endeavouring to se- parate the genuine from the spurious writings of Hippocrates; and in such estimation was he held, that for many ages a main object with all writers on medical topics was to comment on the works of Hippocrates, to elucidate his principles by sub- sequent observation, or to support their respective doctrines by his authority. He is mentioned with great respect by Plato, Celsus, and Pliny, and by others amonrr the ancients ; Galen speaks of him with a degree of almost enthusiastic admiration, and at the revival of letters the most learned men of the times devoted themselves to the elucidation of his works by glossaries, commentaries, and criticisms of all descriptions. In Italy, Germany, and France, where learning first began to revive, and where the earliest universities were estab- lished, we have, among other illustrious names, those of Alpinus, Cornarius, Hollerius, Ballonius, Mercurialis, Fernel, Heurnius, Sennert, Foesius, Riolan, and Duret,* who, however they might differ in their opinions and practice, all coincided in regarding Hippocrates with equal respect, and considered him as having first placed the study of medicine on its correct basis.-f We are hence naturally led to inquire what were the circumstances, in the intellectual" or lit- erary character of Hippocrates, which produced this powerful impression, and perhaps we may as- sign the following as among the most influential. He appears to have had the sagacity to discover the great and fundamental truth, that in medi- cine, probably even more than in any other science, the basis of all our knowledge is the ac- curate observation of actual phenomena, and that the correct generalization of these phenomena should be the sole foundation of all our reasoning. Every page of Hippocrates proves that he was not without his speculations and hypotheses, but at the same time we perceive that, for the most part, they were kept in subjection to the result of observation, and that when they appeared to be in opposition to each other, he had the wisdom to prefer the latter. Hence his descriptions of par- ticular diseases, after all the revolutions of customs and habits, both moral and physical, are still found to be correct representations of nature, while his indications of cure, and the treatment derived from them, are generally rational and practicable. When we reflect that at this period anatomy was scarcely practised,* that physiology was almost unknown, that the materia medica was nearly confined to vegetable substances, and .of these to such as were indigenous to Greece and * In designating the names of authors who flourished after the revival of letters, it is somewhat difficult to determine, whether we ought to employ their actual or iheir latinized names; we have adopted the former, where it could be done without ambiguity or the ap- pearance of affectation. t Corring, Iutr. cap. 3. § 8 et alibi. Haller, Bibl. Med. Prac lib. vi.; it is entitled " Schola Hippocratica," and is carried down to the beginning of the seventeenth century. tOruner, Analecta. diss. 2. " Hippocrates, corpora humana insecnerit necne?" He discusses the question withlmuch learning and candour, and decides in the ne- gative. Vol. III. — 24 ft* the neighbouring countries, our admiration of the skill and talents of Hippocrates will be still farther increased, and we are induced to regard him as one of those rare geniuses, who so far outstrip their contemporaries as to form an sera in the his- tory of science. With respect to the particular improvements which he introduced into the practice of medicine, we may remark that one of the first importance was the narration of individual cases of disease, a plan which may perhaps have been suggested to him by the votive tablets deposited in the tem- ple of J3sculapius, but upon which he so far im- proved as to be entitled to the merit of an inventor. The second point on which we shall remark, was his method of endeavouring to remove particular symptoms by carefully noticing what have been termed the juvantia and the laedentia, watching the effect of his applications, and proceeding, by a cautious analogy, from individual facts to more general conclusions, and hence deducing his indi- cations of cure from the operations of remedies, not from any preconceived or abstract principles, which were generally either fallacious or inappli- cable. Hence his practice may be characterized as consisting in what has been termed a rational empiricism, where we first ascertain the fact, and afterwards reason upon its consequences. In speaking of the writings of Hippocrates, it may be proper to remark that the most complete edition of them, in all respects, is that of Foe'sius, in which every circumstance is attended to that can illustrate them or render them more easily in- telligible. He has given a list of all the commen- taries and criticisms that had been written upon them, which at the time of his publication, in the year 1595, would of themselves have formed an extensive library. It appears from this list that no less than one hundred and thirty-seven authors had published on the subject of the Aphorisms alone. It was remarked above that many of the writings which are commonly ascribed to Hippo- crates, or at least are published in the collection of his works, are supposed not to have been his genuine productions, and hence it has been an object of interest with many eminent critics to distinguish the one from the other. It will not be necessary for us to enter into these discussions in this place ; we shall only remark that the number of treatises which are admitted to be certainly genuine is very small compared to the whole num- ber popularly ascribed to him. Of those which are printed in the ordinary editions of his works, which amount to more than sixty, Mercurialis, Haller, Gruner, and other critics conceive that there are a few only whirls were actually written by Hippocrates, while Aci-crmann has reduced the number of the genuine v. irks to ten.* In ascertaining what were the real opinions and practices of Hippocrates, besides the difficulty of discriminating the genuine from the spurious pro- ductions, we have a farther difficulty arising from the peculiarity of his style. This is admitted to * Conring, cap. 3, § 8. Clerc. par. 1, liv. iii. ch. 30. Mercurialis, Censura et Dispositio Operum Hippocratis. Gruner, Analecta, No. 2. Kuhn, Bib. Med. p. 167-171, for the editions of Hippocrates. Haller, Bihliotheca Vc-d Prac. lib 1. § 17-21. Eloy, Did. hist, in loco. Jckcrmann, Inst. Hist. Med. per.!, cap. 8, § 102. Blumen- bach, Imrod. § 34. Goulin, Enc. Metn. Medecme, " Hio- pocrate," p. 202-5. 186 MEDICINE, (HISTORY OF) be brief and abrupt, and to be full of ideas com- pared with the number of words employed to con- vey them, so that it appeared somewhat obscure even to his contemporaries and immediate succes- sors. Erotianus, who lived in the first century of the Christian era, thought it necessary to write a glossary for the express purpose of elucidating his phraseology; and the immense number of commentaries which have appeared, and which continued to be published until the commencement of the eighteenth century, must be regarded, not only as a tribute to his extraordinary merit, but in some measure as an indirect censure of his style. But after making all due allowance for these pe- culiarities, after rejecting all the doubtful works and obscure passages, and resting more upon the general scope and tendency of the treatises than on particular words and phrases, we have sufficient evidence left us of the nature of his principles, both as regards theory and practice. Although it is principally in the latter capacity that we are now to regard Hippocrates, yet it will be proper to make a few remarks upon his acquirements in the analogous departments of science. With respect to his philosophical tenets it ap- pears that the father of medicine must be classed generally among the Pythagoreans, and in the par- ticular sect or school of Heraclitus. The leading doctrine of this philosopher was, that fire is the prime origin of all matter, and that by the colli- sion and peculiar combination of its particles, which are in perpetual motion, the four elements are produced. (Enfield, b. 2, c. 14, v. 1. p. 436 et seq.) From this doctrine Hippocrates derived his leading principles of pathology ; it lies at the foundation of all his medical hypotheses, and is brought forward in various parts of his works. But although, like all his contemporaries, and in- deed nearly all his successors up to the present day, he assumed certain theoretical principles, yet, as we remarked above, he had the extraordinary sagacity to perceive the necessity of detaching medicine from what was then styled philosophy. He professed to examine the phenomena of disease in the first instance, to ascertain what were the natural powers and properties of the animal frame, how far these were affected by external circum- stances and by morbid causes, and hence to derive his curative indications and his mode of treatment. It is in the writings of Hippocrates that we ob- serve the first traces of what is properly styled physiology, i. e. an account of the functions and powers of the living body. Although some of his opinions were derived from the school of Pytha- goras, and savour of its mysticism and obscurity, yet others appear to have been original, and founded upon a much more correct and philosophi- cal view of the subject. We owe to him the in- vention of the hypothesis of a principle, to which he gives the appellation of nature (